The Politics of Mental Health


The Politics of Mental Health

Highlights from Symposium 2019

By Bessel van der Kolk

May/June 2019


All human endeavors are intrinsically political, including the way our mental health system is organized: how mental problems are diagnosed, what kind of research gets funded, and what treatments are approved as “evidence based,” as well as what interventions are reimbursed by insurance companies.

The story of how the diagnosis of PTSD came into being is a good example. Back in the late ’70s, it became increasing difficult to ignore the fact that hundreds of thousands of Vietnam veterans were profoundly disturbed after coming back from the war. They sought treatment because they kept blowing up with rage, were unable to calm themselves down and go to sleep, and because they couldn’t feel fully alive in the present. Given the political and economic consequences of acknowledging the connection between the struggles these vets were having and their combat experience, the Department of Veterans Affairs (VA) tried to define the problem as a matter of individual pathology. In effect, they wanted to blame these guys’ troubles on their genetics and upbringing.

Through a hard-fought political process, involving veterans organizations and mental health professionals, the diagnosis of PTSD eventually was created in 1980. Part of the politics of the process was that we had to make that direct link between vets’ struggles and their combat experiences. Hence, we focused on nightmares and flashbacks—intrusive memories of traumatic combat experiences—while downplaying problems with emotional engagement and emotion regulation, issues that we gradually came to understand as being the result of trauma changing fundamental brain processes. To this day, the PTSD diagnosis focuses on having unpleasant memories of the past, rather than on emotion regulation and having problems fully engaging in the present.

Subsequently, a number of us who’d been involved in that first step progressed to the next issue: PTSD was a pretty good diagnosis for war veterans, but it was clear that there’s a much larger population of traumatized people. For every vet who comes back messed up, there are at least 30 kids who get abused, molested, abandoned, and neglected at home. Even though they’re quite different from combat vets in many ways, they show many of the same symptoms. In response to our lobbying, the American Psychiatric Association funded a field trial for a new diagnosis: complex PTSD or DESNOS. After that study was completed, the PTSD committee voted 19 to 2 to create a new diagnosis in the DSM. But to our amazement, that diagnosis was eventually left out of the DSM-IV, despite overwhelming research evidence for a much more complex developmental response to trauma.

As a result of that political decision, we still don’t have an accurate way of diagnosing the majority of patients who were traumatized in the context of their early attachment relationships. The DSM gives us a plethora of options: PTSD, Disruptive Mood Dysregulation Disorder, Reactive Attachment Disorder, Dissociative Identity Disorder, Nonsuicidal Self-injury, Intermittent Explosive Disorder, Disinhibited Social Engagement Disorder, Conduct Disorder, or Borderline Personality Disorder, all depending on the clinician’s whim and what will optimally be reimbursed by insurance companies. However, all these “diagnoses” ignore the most common etiology of these disorders: early trauma and disruptions in the safety of the attachment system. If we were to acknowledge the social realities that give rise to these conditions, we could stop looking for some mysterious biochemical or genetic origin that keeps innumerable research labs in business and start putting our resources into becoming a public health system that focuses on prevention and repair, creating optimal conditions for children and young adults to develop and to thrive.

There’s another side to the story of the PTSD diagnosis. Once it was formally recognized, a substantial amount of research money became available to develop “evidence-based” practices. I’ve always been a great proponent of the need to demonstrate the efficacy of mental health treatments, including how well they work, for whom, and what their limitations are. In fact, my colleagues and I have published numerous peer-reviewed scientific papers on the efficacy of a variety of psychiatric treatments, from Prozac to EMDR, and from yoga to theater programs and neurofeedback. However, the rush to evidence-based treatments, paradoxically, had a devastating effect on our field. In effect, the moment researchers found that their particular treatment approach was better than doing nothing, they declared it evidence based. That made some sense, but then politics took over from honest scientific exploration.

Currently, the science of treatment development is largely stuck, because most research funding is focused on basic mechanisms, correlations, neuroimaging studies, and epigenetics, while there’s virtually no federal research funding available to investigate truly innovative treatments. Only the most easily protocolized treatments, like CBT, prolonged exposure, medications, and EMDR, have been thoroughly researched. Interestingly, though medications have been shown, over and over again, to be only marginally helpful for PTSD, they keep being prescribed to the tune of billions of dollars per year. In contrast, somatic therapies, such as Sensorimotor psychotherapy and Somatic Experiencing, haven’t been thoroughly researched for their efficacy, nor has hypnosis, which for about a century was widely regarded as the treatment of choice for PTSD. There’s also little “hard” evidence for Internal Family Systems therapy, or neurofeedback, even though many clinicians who specialize in the treatment of traumatized individuals consider these among the most effective treatments currently available.

The result of the politics of diagnosis and “evidence-based” treatments is that in most settings that depend on insurance reimbursement, clinicians are mandated to use treatments of questionable efficacy. The fact that study after study shows that these mandated treatments have at best a 40 percent drop in symptomatology, which is only slightly better than placebo, after a third of the patients drop out, seems not to have raised enough concern about wasted lives and wasted resources to affect their growing influence. Meanwhile, the VA, by its reliance on evidence-based approaches, has been a major factor in discouraging the expanded exploration of effective treatments. So once again, we’re faced with a political reality: many of the treatments sophisticated clinicians would consider most effective are only available to people who can pay out of pocket.

The impact of pervasive trauma in our society continues to be largely ignored. We know today that one out of eight kids in the U.S. has been a victim of maltreatment, and that half of all kids in the world are exposed to extreme violence. The Adverse Childhood Experiences studies have demonstrated that early exposure to family violence and emotional abuse is the largest and costliest public health issue in America. As a society, we mobilize against threats like ISIS, but most American kids are not the victims of foreign terrorists; they’re the victims of the social conditions in which they mature.

So the question is why, as a society, do we continue to avoid recognizing the devastating impact of early abuse and neglect? Here, again, politics is at play. In most of Europe, Singapore, Japan, and Korea, governments have incorporated evidence of the devastating effects of family violence, social deprivation, and poverty into public policy. In effect, they’ve said, “Okay, we’ve got to try to abolish poverty and spend our tax money on making it safe for children to grow up in our society.” In the States, we have yet to do that. Maybe this is one of the factors that accounts for the incarceration rate in the Netherlands being 68 out of 100,000, while in the U.S. it’s 860 out of 100,000. We’re the only country in the Western world that doesn’t have early parental leave; our mental and physical health depends more on our zip code than our DNA code. Acknowledging the reality of early deprivation, abuse, and neglect inevitably would lead to an invitation to change the social system. But the fields of psychiatry and psychology have failed to squarely face that reality.

As long as we live with a diagnostic system without scientific validity, all of us are part of the problem. Too often, we label our patients with the diagnoses that are in line with what the insurance companies will reimburse us for, rather than what’s actually going on. In fact, many clinicians confide to me that they don’t bother making diagnoses at all. But how can you treat anybody and ask to be paid for your services if you don’t have a clear idea of what’s wrong and what you need to do to fix it? How would you feel if you went to a cardiologist who gave you the treatment that the insurance company will pay for without really bothering to find out what’s wrong with you? How can we respect ourselves, and be respected by our non-mental health colleagues, if we continue to rely on the opinions of insurance companies and ignore the basics of good diagnosis and a solid scientific approach to clinical care?

If people distrust mental health professionals, they may have a good reason for it. We’ve become slaves to the insurance companies, and until we start dealing with the politics of mental health care today, we’re stuck. It’s nice and comforting to come to the Networker Symposium and see so many of our colleagues doing such innovative work. But this conference isn’t the world that we live in. We need to recognize the politics that are shaping our field and let our voices be heard outside the walls of this hotel.

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Bessel van der Kolk, MD, is the author of The Body Keeps the Score: Mind, Brain, and Body in the Healing of Trauma and more than 160 peer-reviewed scientific publications on trauma, mechanisms, and treatment.

PHOTO BY SAM LEVITAN




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12 Comments

Friday, May 10, 2019 8:27:32 AM | posted by Michael Bergeron
Hurray! Bravo! I continue to subscribe to the wisdom of Dr. V and value his training and experience. articles such as this continue to prove his leadership in our profession.

Friday, May 10, 2019 4:30:09 PM | posted by Jeff Ball
I agree that our diagnostic and treatment systems are broken. The DSM is an extremely flawed instrument in that it is based upon a medical model that is inadequate to explain most psychological issues and human experience. We would be much better off diagnosing cognitive and emotional states and experience rather than people, as it would normalize what we typically pathologize as well as introduce context into when and where psychological problems interfere with daily living. It would also allow for understanding of the traumatic origins of many psychological states and experiences. We also need to utilize the least invasive treatment approaches first before resorting to medical interventions, particularly in cases where the efficacy has been greatly called into question and the side effects can be so debilitating (such as benzodiazapines, anti-depressants, and stimulants). While there are appropriate uses for low doses of medication (ideally to greater facilitate therapeutic and experiential interventions), these are grossly overused (and 80 percent overprescribed primarily by non-psychiatrically trained physicians) and inappropriately utilized due to frequent misdiagnoses. However, the political and financial realities make these changes and improvements to the current system unlikely.

Saturday, May 11, 2019 11:20:39 AM | posted by Denise
I suffer from cPTSD. Undergoing tx now via EMDR. The inequity, lack of acknowledgement of this mental injury by the medical community and insurance companies, mis-diagnosis that occurs as a result, are devastatingly painful. No one, no one should have to endure this and be at the mercy of mis-informed, uneducated providers. I tell you this - if a physician or CEO of an insurance company had a child with cPTSD, this would be so very different in an instant. I want to know how to be a part of the solution. How to help inform, how to change the ‘system’

Wednesday, May 15, 2019 9:28:52 AM | posted by Yvonne Hertzberger
"So the question is why, as a society, do we continue to avoid recognizing the devastating impact of early abuse and neglect? " Yes, this is entirely political as well as financial. The only thing that will affect positive change is the recognition that we are responsible for it - as a society. We need to stop looking for solutions that will maintain the corporate and political status quo, the power structures that fail to admit that they are precisely where the problem lies. But giving up power and accepting responsibility means giving up some control, something so few are willing to even consider.

Sunday, May 26, 2019 10:09:44 AM | posted by Pat
I’m sorry to hear that this is the situation in USA and even sorrier to believe that in U.K. we are following your lead. So the best thing is to read these words which throw a spotlight on the Emperor’s New Clothes. What’s happened to the voice of professional psychotherapists? We believe our experiences in the therapy room speak louder than the theories that underpin the work. Individuals are more than the sum of their physical parts and the human brain, which includes the body, is more complex than the chemicals present or not. More, not less, research must be funded. Insurance has less to do with real medicine and more to do with stocks and shares.

Tuesday, June 4, 2019 3:59:24 PM | posted by Rosalind L. Savary
This is an excellent article around ptsd in the context of the politics of mental health especially as it relates to diverse vulnerable persons and groups who are dependent on the systemic process for internal and external courage to move forward. Rosalind Savary MSW, RSW Certified Mindfulness Specialist

Tuesday, June 4, 2019 6:12:13 PM | posted by daisy swadesh
Thank you Bessel van der Kolk for a extraordinarily succinct diagnosis of a problem that is adversely affecting millions of people. I wish I could say more here about this but it will have to wait. You mention the prolonged search for a mysterious biochemical or genetic cause of mental problems. Why have some in the field remained so stuck in this? Mental problems exist because of our large cerebral cortex and a social brain that develops for the most part postnatally, depending on lived experience. To give a simple example, we are born with the potential to speak language but must be spoken to in one (or more) language in order to learn it. And Harry Harlow demonstrated some 70 years ago that even a baby rhesus monkey couldn't become a socially healthy member of a group if left in isolation. Why have these obvious things been missed?

Thursday, June 6, 2019 10:38:42 AM | posted by daisy swadesh
(In answer to my question Cont. )--To understand humans and what is healthy and unhealthy behavior, knowledge from other fields of science is needed--of our human brain and it's evolutionary development, both the cerebral cortex (thinking brain) and the social brain (midbrain and brainstem) which we share to some extent with all mammals; about childhood development, especially the first years when the postnatal brain is tripling in volume, and about mothering--the caring and attuned behavior of primary caregivers who put the baby's needs, especially their emotional needs, as equally important as their own. Why have the decision makers in the APA ignored so much essential scientific data? My personal experience began to provide an answer 60 years ago and has been affirmed by many other events. I came across the Oedipus complex in 1958, just as I was struggling to deal with incest in my family. Due to the specific circumstances I recognized it as a lie, a perfect cover up for a perpetrator to say that childhood memories of sex with adults was a child's fantasy and that the child wanted it and that even pre-pubescent children could accurately imagine adult behavior without having experienced it. I said nothing for over 20 years. But then the women's lib movement of the 1970s and women's magazines broke the silence and brought the discussion out into the public. The diagnosis of PTSD greatly helped, and also Jeffrey M. Masson's book--The Assault on Truth: Freud's 5 month trip to Paris and the presentations at the morgue of children raped and murdered. Freud's paper 11 years later--The Aetiology of Hysteria--the intense pressure to ostracize and silence him and his capitulation. The appalling treatment of Sandor Ferenczi over 30 years later for which there was written documentation in letters. (And wasn't the original Greek myth that the God's were punishing Oedipus' father?--for violating a position of trust of a minor?) There was also the treatment of John Bowlby and D.L. Rosenhan. Then, in 1985, the cases of the sexual abuse by priests in the Catholic Church reported in National Catholic Reporter beginning then--and psychiatrists were advising the Church. Is the refusal to recognize Developmental Trauma a cover up of the cover up? In any case, the refusal to address the real nature of trauma as affecting the ANS is blocking recovery for millions of war veterans and survivors of child abuse. It is professionally criminally irresponsible behavior that endangers the whole mental health system. And in addition has left the Mental Health system unable to address the growing crisis being caused by our perpetrator-in-chief. I'm deeply thankful to the thousands of mental health professionals who have continued making progress on child abuse and its healing despite this appalling situation, but talking about it is not enough. A #MeToo movement and action is needed. I hope PsychNetwork will be courageous enough to publish this.

Friday, June 7, 2019 3:07:52 PM | posted by daisy swadesh
P.S. My second comment certainly could use some judicious editing. But to be more direct, in 1958 Freud's Oedipus complex sounded questionable to me. In 1984 Masson's book Assault on Truth shows Freud hypothesized that Hysteria was caused by the sexual molestation of children. Why did he capitulate? Back then incest was common, including in wealthy and well-educated families. Sandor Ferenzci was pilloried for coming to a similar conclusion in the 1930's. The decision makers of the DSM have refused to address trauma in childhood since the first major statistical evidence in 1985. Why? Is it a cover up?

Saturday, June 8, 2019 10:42:33 PM | posted by Dr Delia Anastasia Bernardi
Indeed Dr van der Kolk. Another example would be that interventions which are typically court-mandated for perpetrators of intimate partner violence are those based on the feminist psychoeducational Duluth-type model, even though their effect size prove to be minimal in reducing recidivism. Patriarchy could possibly have sufficed as a theoretical framework in the early 1900s where abuses against women were depicted against a backdrop of the suffragettes who campaigned for equal voting rights. However, today the concept of intimate partner violence is much more broader than a political agenda for equality and the empowerment of women. A plethora of evidence points to an often intergenerational transmission of violence into adulthood and that partner abuse is not gender bound. International directives should include the elimination of violence against women and children and men.

Sunday, June 9, 2019 12:35:23 PM | posted by Tom
Thank you Dr. Van der Kolk for speaking up about our seriously broken health care system in general and our sad state of affairs in the field of mental health and trauma/PTSD. As a NYS licensed mental health counselor and a Vietnam Veteran, I was involved with research on the use of Emotional Freedom Techniques/EFT tapping, on veterans with PTSD, carried out by the Veterans Stress Project. We experienced exceptional, sustainable results. There are many peer reviewed and published studies about using EFT on PTSD. Our lead researcher, Dr. Dawson Church, went to the House veterains affairs committee with the results several years ago and basically was ignored. Some research was supposed to be conduceted at Bethesda hospital, and for what ever reason, it never happened. It is only in the last year that the VA has given any credence to the research and the technique by placing it on its list of "considered generally safe" techniques. Meanwhile, our veterans continue to suffer, be prescribed numerous, ineffective medications and receive mental health treatments that just don't work well or don't have sustainable outcomes. Research has show that EFT tapping not only works, it produces sustainable outcomes. EMDR is also an exception as it does produce exceptional, sustainable outcomes. On several ocassions over the years, beginning in 2005, I have talked to various contacts inside of the VA, and like Dr. Church, I got nowhere. Like you, Dr. Van der Kolk, I am frustrated about our mental health system in general, not just with the VA. There are other problems that affect LMHCs in NYS and those don't need to be aired here. Like you and others, I ask "what is it going to take?" Again, Thank You for speaking up. We need more voices like yours!

Tuesday, June 18, 2019 10:07:00 AM | posted by Gianna Kudar
I am a psychiatric nurse working in an inpatient involuntary psychiatric unit in a hospital in Northern California. I was so tired of treating emotionally traumatized patients with medication. I started searching for something that I could do to help this population. I stumbled across Trinity Wellness Group, owned by Anna Apple. I listened to amazing stories of emotional healing from traumatic events. I have my own trauma from sexual abuse from the age of 3 to age 10, which has affected every part of my life. I went through the somatic integration therapy and now feel powerful and free. Anna and I spoke to my director about the therapy and she gets it! She had read your book The Body Keeps the Score and she had to reread it and it all makes so much sense to her. We are in the process of adding a Trauma therapy group to the unit where I work. I believe medication can help but more is needed!