May, as one of Washington Psychiatric Society's Assembly Representatives:
1. That there be annual awards for District Branches that have the largest increase in their Membership.
2. That the APA explores the issue of providing DSMs free for all APA Members [WPS motion].
3. Relative to DSM-5, that dimensions be located in the part of the DSM listing proposals in need of further study.
4. That the APA oppose implementation of the ABPN's PIP requirements for Maintenance of Certification until scientific evidence has shown that those requirements improve quality of care [not lead author].
5. That the APA engage in a periodic review of its position on networked electronic records to ensure it remains current with the fast changing environment, technology, and security breaches, and authorize referral of its existing policy to the appropriate committee for review and updating as appropriate. Also, that the APA strengthen educational materials for use by both the public and clinicians that addresses advantages and disadvantages of electronic medical/psychiatric records so that all can be well informed on the degree of safety and the maintenance of proper standards of privacy and confidential for networked electronic psychiatric records [not lead author].
6. That the APA establish a Council on Global Psychiatry [not lead author].
7. That there be a process that makes it easier for Assembly motions to get to the Board of Trustees [not lead author].
8. That the APA has a mechanism by which Sections could be created. Sections would be organizations within the APA for interests not otherwise available in psychiatry. For example, there are over 3,000 counties in the US, counties are being held more and more responsible for the delivery of public psychiatric treatment in this country, yet there is no organization that speaks to the issues of psychiatric care that is provided by counties.
1. Assembly passed RP motion asking the APA to
support the Mental Health America resolution calling
on President Obama to reverse the policy on not
sending Presidential Letters of condolence to
families of service members who have completed
suicide. Now APA policy. Huge help from Michael
Blumenfield with this motion. In 2011, White House
began sending out such letters to the families.
2. Assembly passed RP motion calling on the Assembly
to establish a task force to explore ways in which
the APA Practice Guidelines can be kept current.
It took over a year for the APA’s governance
to process the Guideline on Major Depressive Disorder.
We want to see the governance viscosity cease.
3. Assembly passed a motion developed primarily
by Eliot Sorel and Anita Everett calling on the
APA to adopt the position paper, Psychiatry and
Primary Care Integration Across the Life Span.
My role was primarily process, not content.
4. Board of Trustees passed a motion that documents
being addressed by the Board be sent out immediately
if the APA President agrees.
5. A motion that any billing that requires reporting
of the Multiaxial system is inappropriate and
6. A motion that a conservative approach be pursued
as to DSM-5 coding of dimensions in DSM-5.
7. A motion that APA officers be encouraged to
use “FAPA” and “DFAPA”
in their official communications.
Lost election for President-elect, getting 30% of the vote in a three-way race. Campaign material is at the end of this part of the website, below “1977.” Reelected as WPS Assembly Representative, 2009-2012.
Action Papers for May 2009 Assembly:
A. On Equity.
1. The Assembly Committee on Public and Community Psychiatry [ACPCP] explore, think-tank like, the issue of equity as it should apply to people with psychiatric illnesses, and report to each Assembly as to their progress on this issue.
2. The American Association of Community Psychiatry be invited to provide their thinking on the need for equity to the ACPCP.
3. The American Association of Social Psychiatry be invited to provide their thinking on the need for equity to the ACPCP.
B. On Improving APA Website. Primary author, Judith F. Kashtan, M.D., Rep, Minnesota Psychiatric Society.
C. On APA sponsored programs Primary author is Joseph Napoli.
1. That The Scientific Program Committee and the Institute for Psychiatric Services Scientific Program Committee in collaboration with APA CME staff shall, in accordance with ACCME standards for CME activities, plan, organize and implement a series of symposia on the current diagnosis and treatment of mental disorders. Each symposium would be focused on:
A) Diagnostic category, such as Anxiety Disorders, Impulsive Disorders, Substance Use Disorders
B) Major mental diagnosis such as Dementia, Major Depressive Disorder, Bipolar, Posttraumatic Stress Disorder and/or
C) Personality Disorders and updated annually and presented at the APA Annual Meetings and at the IPS Meetings
2. That the cost of these symposia shall be kept to a minimum so that registrants of the Annual Meeting and the IPS can attend them without paying any fee additional to the registration fee for admission to the general meetings.
3. That cost containment shall be achieved by not having meals, not employing educational companies, simplifying audiovisual needs, providing no honoraria or travel expenses
4. That the American Psychiatric Foundation or the APA [Medical Director's decision] shall seek unrestricted educational grants from potential commercial supporters only after the program, including its content and faculty has been completely set and without any communication between the educational activity planners, directors and faculty
5. That syllabi and audio or video recordings of the symposia shall be available for purchase at cost.
D. On position on CME & Disclosure, primary author Barry Herman.
1. that the APA focus its efforts on developing sufficient safeguards to ensure the integrity of the content of CME regardless of it source of funding
2. that the APA implement a policy to not promote, endorse and/or use any CME product for which a current or past member has a personal financial interest in excess of $10,000 per year, and to require such financial disclosure from current members related to CME in all APA-related activities.
E. Relative to keeping Practice Guideline
1. The Steering Committee on Practice Guidelines:
a) Explore with the Academy of Psychosomatic Medicine (APM) whether APM can maintain the Practice Guideline on Delirium.
b) Explore with the American Association of Geriatric Psychiatry (AAGP) whether
AAGP can maintain the Practice Guideline on Dementia
c) Explore with the American Association of Addiction Psychiatry (AAAP) whether
AAAP can maintain [and expand] the Practice Guideline on addictions.
d) Should any of the three explorations supra seem promising, that the Steering
Committee on Practice Guidelines proposes to the Assembly a process for
approval of those proposed Guidelines.
e) That the Steering Committee on Practice Guidelines report on its findings on this topic to the November, 2009, Assembly.
F. Relative to components that have been sunsetted in 2009. The Assembly Committee on Procedures determine whether the Assembly might authorize and re-establish some of the sunsetted components at no costs to the APA], and, if so, what they would propose be the process.
G. Relative to gender identity disorder, The American Psychiatric Association declares that:
1. Gender identities and expressions which differ from assigned sex or cultural convention do not, in themselves, constitute mental disorders, and imply no impairment in judgment or competence.
2. The medical literature has established the effectiveness and medical necessity of mental health care, hormone therapy, and/or sex reassignment surgery in the treatment of patients diagnosed with Gender Identity disorder.
3. The APA supports public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults, and opposes categorical exclusions of coverage for treatment of gender identity disorder in adolescence and adults when prescribed by a physician.
H. Relative to reducing Assembly expenses.
Barry Herman primary author. BE IT RESOLVED:
1. that beginning calendar year 2010
for a period of two years Assembly members pay
for, with the exception of transportation expenses,
their own hotel, food, and incidental expenses
associated with attendance at all Assembly and
2. that these expense obligations
not be required of MIT Assembly members or ECP
Assembly members in their first year of practice
3. that in demonstrated cases of hardship these
expense obligations may be waived to be considered
on an individual basis by an ad hoc committee
appointed by the Speaker
4. that the Assembly
officers voluntarily reduce their honoraria and
travel expenses by 25 percent in years 2010 and
5. that the AEC pre-specify organization
financial milestones by which this policy would
remain in effect, and reevaluate at the end of
two years and, if necessary, annually thereafter.
6. that the Assembly Executive Committee examine
the cost savings that would occur with the implementation
of this policy and determine if any further budget
adjustments are necessary.
Roger Peele has been on about a 100 APA, DB, Chapter, and other professional organization components -- including being a voting member of the Board of Trustees for 11+ years [more than any other voting member of the Board], member or guest of the Assembly for 33 years [including being Speaker], and on his DB’s Board of Directors for 34 years. Listed below are some of the statements he has developed for President-elect. Further is a listing of some activities by year, a listing that remains incomplete.
[As has been true of every year, the following motions almost always involved others]
November, 2008, motion to the Board of Trustees to give Corresponding Members of components voting rights. [They are now non-voting members.]
The following motions passed the Washington Psychiatry Society or the Maryland Psychiatric Society in the summer of 2008 and went to the November Assembly:
Have the APA’s DSM-V Task Force explore DSM title changed from its present approach to the year published, e.g., “DSM-2012,” rather than “DSM-V.” Passed Assembly in November.
Explore having the APPI book, QUICK REFERENCE, include the AACAP Practice Parameters. Passed the Assembly.
That the American Psychiatric Association challenge the concept of “me-too drugs” in psychiatry. First Author, John Shemo. Postponed till the May Assembly.
A coauthor of motion with Robert Roca, who was the primary author, to have the APA develop a guide on the use of antipsychotics in patients with dementia. Accepted by Board for their December meeting’s agenda.
A coauthor of motion, with Robert Roca, who was the primary author, to have the APA advocate for consideration of psychiatric practices as Medical Homes during the demonstration phase of this federal project.
A coauthor of motion, with Herb Peyser, who was the primary author, to have the APA pursue adequate payments within the RBRVS system.
A coauthor of motion, with John Shemo, who was the primary author to have the APA advocate for the CPT code 90862 be changed in line with the E/M codes.
A coauthor of motion, with Herb Peyser, who was the primary author, to have the Assembly establish a study group to monitor and make recommendations on the Assembly-Board relationships.
The following have passed the Washington Psychiatric Society and Area III in early 2008:
Hind Benjelloun was the primary author of an Action Paper that the timing of the Psychiatric Services Institute be move from October to coincide with the Component Meeting in early September. Motion would also abolish the Corresponding Committee status. Passed May Assembly and referred to JRC.
New Jersey DB was the lead on an Action Paper calling for the APA to champion the definition of “Evidence-Based Medicine” as “The integration of best research evidence with clinical expertise and patient values.” Passed May Assembly.
Barry Herman was the lead of an Action Paper on facilitating the ability of APA District Branches to provide psychiatric consultation to primary care physicians. Passed May Assembly.
Action Paper on Redefining NOS criteria in DSM-IV-TR. Passed May Assembly.
Action Paper on having the Assembly formally review the proposed APA budget. Passed May Assembly after modification.
Jeff Giller was the primary author of an Action Paper on veterans having access to involuntary psychiatric hospital beds. Passed May Assembly.
Action Paper stating that the APA Bylaws should be changed to have each Area decides who represents them on the Nominating Committee. Passed May Assembly.
Action Paper asking that the Board of Trustees agree to a procedure/policy by which it would agree to abide by the Assembly’s decision. Postponed until November Assembly.
Action Paper to abolish the prohibition against a minority member voting in more than one caucus. At the May Assembly, referred back to the UR caucuses.
Eliot Sorel was the lead on an Action Paper asking that the APA arrive at recommendations to enhancing the care and treatment of the mentally ill by primary care physicians. Passed May Assembly.
A motion from the Washington Psychiatric Society to the APA Work Group on Conflicts of Interests, that the term “conflict of interest” be replaced with “potential conflict of interests.” Referred directly to conflict of interests' task force.
A Statement to the Board of Trustees from the Washington Psychiatric Society declaring that the American Psychiatric Association should return to the reason the APA was founded in 1844, to wit: explicating, promulgating and advocating for the humane care and effective treatment of people with mental illnesses, that to do so requires that the DSM and Practice Guidelines be current.
Statement to the American Psychiatric Association [APA] From Washington Psychiatric
Societyon the Priorities of the APA
The Washington Psychiatric Society asks that the APA give its priority to the reason that the APA was formed 164 years ago: to explicate, to promulgate, and to advocate the humane care and effective treatment of people with psychiatric illnesses. Unless the APA is the authority as to the clinical needs of people with psychiatric illness, it loses its foundation, a foundation that is crucial to reaching its other advocacy interests.
In recent years we are seeing an erosion of the foundation on which we are standing. Some examples:
1. A substantial development since DSM-IV was published  is the huge expansion of youth being given the diagnosis of bipolar disorder. The APA, despite a request from this District Branch to do so, has not provided leadership on when children and adolescents should be given the bipolar diagnosis.
2. A substantial development since DSM-IV was published  is the expansion of ADHD diagnosis in adults. The APA, despite a request from this District Branch to do so, has not provided leadership as to when the ADHD diagnosis should be given to adults.
3. In 2005, the federal government changed the sleep classification in this country, ICD-9-CM, by adding more than sixty new sleep disorders. Sleep complaints are among the most common symptoms of psychiatric patients. While a few modifications in the printing of DSM-IV-TR were made a couple of years ago, the APA has been silent as to the usefulness of ICD-9-CM’s 81 sleep disorders.
4. About two decades ago, the South Florida District Branch and this District Branch successfully move that the APA develop practice guidelines. These guidelines are not being kept current.
5. American psychiatry’s only unique etiology, relative to other medical specialties, is mental trauma. On October 17, 2007, the Institute of Medicine released its report on the management of PTSD that stated: “The evidence is suggestive but not sufficient to conclude efficacy of SSRIs in general populations with PTSD. The available evidence is further suggestive that SSRIs are not effective in populations consisting of predominantly male veterans with chronic PTSD.” For the months since the IOM report, the APA has provided no leadership in responding to this statement, a statement that is so important clinically and is related to our special interests in seeing the veterans are well served.
6. Council on Addiction Psychiatry reported in 2007 that the online buprenorphine course on the APA website “is quite out of date.”
The Washington Psychiatric Society asks the American Psychiatric Association to make explicating, promulgating and advocating for the clinical needs of people with psychiatric disorders its highest priority. Within the American Psychiatric Association’s membership is the expertise to arrive at an authoritative consensus as to the clinical needs of the people with psychiatric disorders. We ask that these resources be utilized to the fullest degree possible to enhance the APA’s clinical, authoritative foundation – so as to enhance the humane care and effective treatment of people with psychiatric disorders, the reason the APA was founded.
(Passed unanimously by the Washington Psychiatric Society, February 11, 2008.)
Passed the following motions to the Washington Psychiatric Society, March 12, 2007:
1. Motion to have the APA explore recognizing the American Academy of Child and Adolescent Psychiatry's Practice Parameters as the resource documents for the American Psychiatric Association as to child and adolescent disorders, like the APA’s Practice Guidelines. Passed with the change from "the resource" to "a resource."
2. Motion to have the APA begin the process of developing a position on the number of state-funded beds that a state should have, a position based on observed needs, not based on hypothesized community resources. Motion went to Assembly Committee on Public and Community Psychiatry.
3. Motion that the APA developed a position on the use of the term “suicidality” that is tied to “suicides” per se. Motion failed.
4. Motion that the APA explore being a resource to the media when the media is developing a film, TV show, etc., in which the psychiatrically ill or psychiatrists are being depicted. Motion failed.
5. Motion that the APA allow its DBs to open up their websites to APA election campaigning. Motion passed.
6. Motion that the APA advocate for psychiatric medications being available immediately in national disasters. Motions primary author is Eliot Sorel. Motion passed.
7. Motion that the APA improve its website to make it friendlier to the profession and to the public. Motion’s main author is Barry Herman, a Pennsylvania psychiatrist who has often worked effectively with the Washington Psychiatric Society to improve the APA’s advocacy for pts and the profession. Dr. Herman decided to postpone the motion depending on promised changes in the website.
8. Motion, primary author was Dr. Barry Herman, that APA establish a component to provide support for members who have been sued.
We all must be pleased to see proposed legislation that addresses this nation’s major remaining discrimination -- the discrimination against those with a psychiatric illness in health insurance plans.
Thomas Jefferson did not write that, “All men are created equal -- except for those with a psychiatric illness.”
At Gettysburg, Lincoln did not say, “our nation is dedicated to the proposition that all men are created equal -- except those with a psychiatric illness.“ Lincoln did not conclude that, “government for the people -- except for people with a psychiatric illness.”
Government’s major function is the protection of the health of its citizens. Protecting the health of its citizens includes, one, stopping military and terrorist acts against our citizens, two, preventing illness and, three, assuring the care and treatment of citizens who are ill. In this country, assuring the care and treatment of citizens who are ill is a mosaic of public and private programs – a mosaic that too often has been permitted to treat a person with a psychiatric illness in a fundamentally different way than someone with another illness.
There is no place in this nation’s basic values that allows, permits, or ignores discrimination against people with a psychiatric illness at any time, and especially within any of our programs dedicated to a citizen’s health.
Discrimination against the people with a psychiatric illness contributes to the fact that this nation largest psychiatric institutions are within prisons and jails.
Discrimination against people with a psychiatric illness contributes to the fact that psychiatric illnesses affect workplace loss of productivity more than other illnesses.
Discrimination against people with a psychiatric illness contributes to the fact that the most common disabilities are those associated with psychiatric illnesses.
But even if the millions of tragedies associated with psychiatric illnesses in this country were not tied to discrimination, this nation should not permit such discrimination -- as it is an offense to our basic values.
It is magnificent to see this Congressional leadership moving to abolish this nation’s last major unaddressed discrimination in health insurance, a move that hopefully will create a climate that discrimination in any component of this nation violates our basic values.
Letters to the Editor, Psychiatric News, February 7, 2007
The recent headlines about someone being discharged from the Army with a "personality disorder" is a reminder that in 2002 the Washington Psychiatric Society and the Maryland Psychiatric Society voted to ask APA to remove the word "personality" from the titles of present disorders (e.g., "histrionic disorder" rather than "histrionic personality disorder"). There is no reason to label some of the psychiatrically ill with DSM-IV's "personality" disorders."
The 10 aggregations of signs that constitute DSM-IV's 10 "personality" disorders do not reflect the total "personality" of patients any more than does autism, Asperger's, mental retardation, schizophrenia, and so forth. Nor are the so-called "personality" conditions any more permanent or pervasive than many other psychiatric disorders. Both borderline "personality" disorder and antisocial "personality" disorder, for example, often remit spontaneously by their fifth decade, some far sooner.
The label "personality" disorder misleads patients, family members, employers, insurance companies, and even some clinicians to think of these patients as having pervasive and permanent psychiatric conditions, i.e., untreatable. APA should take steps to remove misleading diagnostic labels.
Labeling people with these disorders as having a "personality" disorder is hurtful. They may have very positive personalities in many respects, yet suffer from an aggregation of signs that historically APA has labeled a "personality" disorder. APA should remove unnecessarily hurtful diagnostic terms.
The concept of "personality" disorder contributes to misdiagnosing the patient's problems because of clinicians' reluctance to apply the "personality disorder" label to patients, particularly to children and adolescents. This barrier leads to postponing, if not precluding, correct treatment. APA should take steps to change the diagnostic categories when the change will encourage appropriate care and treatment.
The so-called "personality" disorders incorrectly imply a relationship to the basic science on personality. These 10 aggregations are inadequate, if not misleading, in facilitating communication between clinicians treating patients and researchers studying personality. Leaving the word "personality" out of these 10 aggregations and focusing on the impact of personality traits that science is studying places psychiatry closer to the rest of medicine's use of "personality," e.g., specific personality traits impact on the immune system.
Two of the 10 "personality" disorders have names whose problems go beyond the term "personality." The term "obsessive-compulsive personality disorder" is confusing, as these patients don't necessarily have obsessions or compulsions. Further, that label is confusingly close to "obsessive-compulsive disorder." The international community (ICD-10) uses "anankastic" for these patients, a term that doesn't confuse these patients with those who have "obsessive-compulsive disorder." The term "borderline" is inappropriate as it fails to summarize the patient's condition. APA should take steps to encourage an exploration of alternative terms that accurately reflect a patient's condition. Explorations already taking place in some clinical settings include "emotional dysregulation disorder," "dysregulation disorder," and "regulation disorder."
In summary, the proposal from the Washington and Maryland psychiatric societies to remove the word "personality" from the label of these 10 disorders would be a humane step that would facilitate communication and increase access to treatment.
On December 13, 2006, Peele testified before an FDA panel as to expanding the “black box” on antidepressants from children and adolescents to adults under the age of 26. The basis of the expansion was a study showing an increase in "suicidality" in patients who were on antidepressants, not an increase in suicides. Peele's testimony was directed at the lack of connection between what was measured as "suicidality" and "suicide.
Roger Peele, M.D., D.L.F.A.P.A Chief Psychiatrist, Montgomery County, Maryland Clinical Professor of Psychiatry, George Washington University Member, American Psychiatric Association Board of Trustees Member, Washington Psychiatric Society Board of Directors
I come before you as Chief Psychiatrist, Montgomery County government, I come before you as someone who has been responsible for the care and treatment of people with psychiatric illnesses in public or academic settings in Washington, Virginia, or Maryland for the past 46 years, and I come before you as someone who has had four uncles, one aunt, and three cousins commit suicide in the years before we had SSRIs.
In thinking about preventing suicides, are we interested in blocking patient’s willingness to talk about suicidal thoughts? We are not. None of my 8 relatives who killed themselves talked about suicidal thoughts. Many of us have had patients who are alive today because they had become willing to talk about their suicidal thoughts.
In thinking about suicide prevention, are we interested in blocking pts self-injurious behavior? None of my 8 relatives who killed themselves had self-injurious behaviors. We certainly don’t want patients injuring themselves, but it remains that many a clinician has had patients who cut themselves as a way of reducing unbearable anxiety, and in reviewing their histories, one can conclude that if they had not cut themselves, they might well have done something more drastic. We need to remember that the emotion just prior to committing suicide is often not sadness, but an excruciating anxiety in which the only escape seem to be to end one’s life.
In thinking about preventing suicides, are we interested in preventing plea-for-help gestures? None of my 8 relatives who killed themselves had a history of plea-for-help gestures. We certainly don’t want patients to have to resort to such gestures, but it remains that for many a patient, such a gesture is not suicidal but an alternative to suicide.
Using a term like “suicidal” for willingness to talk about suicidal thoughts, for cutting oneself, or for plea-for-help gestures, then basing a black box on the word “suicidal” would lead the FDA to make a promulgation that the experienced clinician knows is based on a fallacious understanding of word “suicidal.”
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The following actions cleared the May, 2006, Assembly:
1. That the APA's Council on Research explored the issue of whether the psychiatrically ill would benefit from the FDA's increased approval of medications for the treatment of signs and/or symptoms associated with psychopathology in addition to approving medications for the treatment of DSM-IV specific mental illnesses.
2. That the American Journal of Psychiatry explore facilitating reporting of clinically significant scientific findings, as articles are now appearing as much as ten months after they have been accepted. Unlike the New England Journal of Medicine, AJP appears to have no mechanism for rapidly informing the profession and the public. NEJM has a mechanism that made it possible for an important finding to be placed on their website 48 hours after receiving it.
3. That the Scientific Program Committee report to the Assembly as to whether there are plans to increase the availability of audiotapes IN THE 2007 Annual meeting, as many valuable parts of the 2005 meeting were not available.
4. [Eliot Sorel primary author] That the APA develop a post-disaster response plan so that, with future Katrina’s, an APA response is ready.
5. [Jonathan Weker primary author] THAT the APA develop and disseminate to APA members a "Strategic Manual " outlining alternative responses to the regulatory and administrative challenges imposed by Medicare, Managed Care Organizations and Pharmacy Benefit Managers.
1. Passed, May, 2005. Have Assembly’s Committee on Planning [COP] explore whether some components that now report directly to the Board, and have COP make recommendations to the Assembly on this topic at the November, 2005 meeting. COP decided against.
2. Passed, May, 2005. [Primary author Harold Eist]. That the APA advocate for laws that address the confidentiality needs of patients when someone, other than the patients, has filed a complaint. Status: Council on Law and Psychiatry report has filed a report that will go to the Board of Trustees in December.
3. Passed, May, 2005. That the APA explore having fetal alcohol disorders added to the next addition of the DSM [primary author: SUSAN RICH]. Placed on DSM-V agenda. [We had hoped for something sooner than 2011.]
4. Motion to form clinical components to keep the DSM, the Practice Guidelines, and APA responses to clinical questions current [with Dr. Maryam Razavi]. Status: Passed WPS Board, passed Area III, passed Reference Committee, failed in Assembly [but issue still went to Practice Guidelines Steering Committee].
5. Motion that the APA form a work group to report to the APA Board of Directors in December as to the need to establish a DSM V Steering Committee. Board agreed to appoint DSM-V Work Group, and appointments were made in 2006.
6. Motion to have the APA explore with PhRMA as to whether we can work with it to reduce the barriers that the current system of managed care places in the access of the psychiatrically ill to care and treatment. [With Drs. Barry Herman and Maryam Razavi.] Passed Assembly and agreed to by the Board in 2006.
1. Change the APA Bylaws to state that the APA’s Chief Executive Officer is the Medical Director. Passed the Assembly, then the Board, then back to the Assembly, effective May, 2005.
2. Do not continue the multiaxial system in next edition of the DSM unless there is evidence that its use over the past two decades has benefited patients with psychiatric illnesses. Passed the Assembly [81 to 49], went to the Committee on Psychiatric Diagnosis and Assessment, which set up a work group to answer this question. The Work Group miss-stated the Assembly motion, developed a document with 78 references on the Multiaxial System and recommended its continuation to the Assembly in Power Point presentation, May, 2005, in which no time was set aside for questioning the report. None of the references identified patients who had benefited. [Rather than go back to this specific issue in isolation, it was decided to make a motion to appoint the DSM-V Task Force – which succeeded in late 2005.]
3. That the APA develop criteria for the diagnosis of bipolar disorders in children and adolescents in the next edition of DSM-IV. Passed the Assembly, and put on DSM-V agenda. [We had hoped for something sooner than 2011.]
4. That the “competencies” of psychiatrists be focused on the concepts and skills needed within “Psychiatric Management of psychiatric disorders” rather than on five specific psychotherapies. Passed WPS and Area III, but failed in the Assembly on a voice vote. [Dr. Razavi was major asset with this motion]
5. That the APA advocate for removal of the present restrictions on the number of patients a physician can treat with buprenorphine. [With Dr. George Kolodner.] Passed Assembly. APA's joined other organizations and achieved legislation and White House signature in August, 2005, lifting the 30 patient limit on clinics, but not yet on the individual practitioner, so remains on APA's do list.
1. Have the APA explore establishing a specific criteria set for Adult ADHD. Passed Assembly and went to the Committee on Psychiatric Diagnosis and Assessment [CPDA}. Passed Assembly. Committee reported back to the Assembly that it would take $300,000 or much more to establish the criteria set. [So, on agenda of DSM-V Work Group. We had hoped for something sooner than 2011.]
2. Have the APA use the word “nondiscrimination” rather than “parity” as the goal [when there is a choice] in advocating for the psychiatrically ill. Passed the Assembly and Board. [We had had this motion also passed in 1982, but decided to repeat.]
3. Have the American Psychiatric Association explore whether the psychiatrically ill would be better served with the term “people with mental disability” rather than “seriously and persistently mentally ill.” Passed WPS and Area III, but failed in Assembly.
4. Have the APA explore the concept of Medicare for all who are willing to pay the full actuary costs [including the costs of state mandates]. ["State mandates" was included so that all of the non-discriminatory state laws would be covered since Medicare discriminates against the psychiatrically ill.] Passed the Assembly, and still being considered by components.
5. “One Form to Obtain Medications”, Have the APA as the AMA to pursue the need for a single form for patients to enter access to their medications, at reduced rates, Assembly, May 16-18, 2003. APA took to AMA and AMA improved motion to call for a website. PhRMA took motion and created Partnership for Prescription Assistance, a website staffed by hundreds, able to handle 175 languages, and has 7 to 8,000 hits a day.
6. “State Support of Psychiatric Hospital Beds”, Have the APA explore establishing a policy relative to the number of psychiatric hospital beds that a state should support, Assembly, May 16-18, 2003.
7. “APA Office of International Affairs”, To request the Council on Global Psychiatry to review the matter of reinstating the Office of International Affairs or to, at a minimum, reinstate the functions performed by the office [with Dr. Al Halpern who was primary author], Assembly, May 16-18, 2003.
1. Have the APA takes steps to remove the term “personality” in its diagnostic terms for people with psychiatric disorders so as to make DSM terms less hurtful, less misleading, less confusing, and more likely to be used when indicated. Have the APA take steps to place these patients on Axis I. Passed Washington Psychiatric Society, Maryland Psychiatric Society, Area III Council, but failed in the November Assembly.
2. Champion the concept that, while the APA advocates that all levels of government and all sectors of society contribute to the humane care and effective treatment of the psychiatrically ill, the ultimate responsibility for the psychiatrically ill is the state. Passed Washington Psychiatric Society and November Assembly. In the 2004 APA Vision Report, this was narrowed to the State being the safety net.
3. Relative to spouses of deceased members a] When so requested by the spouses of deceased APA members, provide them with complimentary copies of Psychiatric News. b] Establish a policy that spouses of deceased APA members are eligible for the same Annual meeting admission fees as “spouses.” c] Authorize the Medical Director to take any other actions for spouses of deceased members that he/she believes are indicated in consultation with the APA Alliance. Passed Washington Psychiatric Society and the November Assembly to become APA policy.
4. Had amendment to Component Composition motion that removed proposed limit on number of people who could be appointed to a given component in that there is to be no limit on number of corresponding members.
5. Establishing APA Position on Rep Payees, November, 2002. American Association Developed a resource report for their organization and the APA.
6. Joining the Class Action RICO Lawsuit against Managed Care, November 2002.
7. Supporting the Class Action RICO Lawsuit against Managed Care, Assembly, May, 2002.
8. Compendium of Practice Guidelines, Assembly, May, 2002. Asked that the APA combine the Practice Parameters of the AAC&AP with the APA’s Practice Guidelines.
9. Balkanization of Medicine, Assembly, May, 2002.
10. Medical Director’s Salary, Assembly, May, 2002. Asked that the APA Medical Director’s salary be established before the search and be about $300,000. Approved by WPS, but not the Assembly.
11. The effect of Medicaid and Medicare policies on access to inpatient care of the serious and persistently mentally ill, November, 2002.
12. Practice Guidelines Include Evidence Bases Services For Serious and Persistent Mental Illness (SPMI), Assembly, November, 2002.
13. Education of Psychiatric Residents and APA Members in the Care and Treatment of Persons With Serious and Persistent Mental Illness (SPMI), To ensure that the education/ training of Psychiatric Residents is substantial and satisfactory in the care and treatment of the SPMI population and to assist in the further education of APA members involved in public sector psychiatry, Assembly, November, 2002.
14. Membership Benefit: FAPA, Assembly, November, 2002. Have APA change Fellowship requirements more like that of the rest of medicine, i.e., “Fellowship” requirement be Board certification and the prior “Fellowship” requirements become those for “Distinguished Fellow.” Idea was developed in the 1990s, but the APA Membership Committee had been unsuccessful in getting it accomplished, so Larry Kline and Peele picked up the baton and got it through the Assembly and Board to become part of APA’s Bylaws.
15. Memberships Benefit: Assistance with Board Preparation, Have the APA assist members who request help for their preparation for written and oral boards and re-certifications, Assembly, November 8-10, 2002.
1. “Carve outs”, Opposition to carve outs in the private sector, Area III, Assembly November 9-12, 2000. Eventually became APA policy. Considerable help from Janis Chester, Larry Kline and others.
2. Redefining Fellowship, Assembly, November, 2000. See “14” under “2002.”
3. Right to Know, Assembly, November, 2000.
4. Managed Care Panels, Assembly, November, 2000. Managed care panels must be current, should be a limit on how long Managed Care companies can avoid updating their list of physicians who are on their panels.
“Keeping APA Practice Guidelines Current”, Area III #10, Assembly, November 4-7, 1999. Led to development of Practice Guideline Watches.
Speech Before the Assembly, November 6, 1999
When I was two years old, my father became mentally ill and was jailed in Durham, North Carolina. This was the beginning of three and half decades of incarceration, primarily in VA hospitals. Many of you had similar experiences that led you to want to improve the conditions of the psychiatrically ill even before you were a physician.
In reviewing this nation’s history to improve the conditions of the psychiatrically ill, one finds that a woman, working with the APA founders, was more successful in improving the conditions of the psychiatrically ill than has been the APA in this century. Dorothea Dix visited a jail in Massachusetts on March 28, 1842, was outraged by what she found, and campaigned for change. When her campaign was 38 years old, in 1880, this nation conducted it only full census to ascertain the location of the insane. That census found the vast majority were at home or in a hospital. Less than one percent were in jails or prisons [393 out of more than 90,000]. Today there are more psychiatrically ill in jails and prisons than in hospitals.
Recently we have heard applause for many deeds within the APA. We should hold our applause until we find that fewer of the psychiatrically ill are being left in pain or being left disabled by managed care. We should hold our applause until we find that fewer of the psychiatrically ill are in jails and prisons and fewer are on this nation’s streets.
Parity legislation and lowering of the ERISA shield have led some to smell victory. That may be illusionary. Consolidations in the managed care field means we are dealing with larger adversaries. Larger adversaries, now wounded, may become even more dangerous for our patients -- and for psychiatrists.
In order to change the fate of the psychiatrically ill, we must express our outrage in a clear, memorable, positive clarion call. While there is nothing terribly wrong about our strategic plan which contains 40 goals, 40 goals are not, cannot, be a clarion call.
Even if we achieved all 40 goals, the psychiatrically ill would not be as well off as they would be if we achieved three rights for the psychiatrically ill.
First, is the right of the psychiatrically ill to be free of their illness, as free as modern treatment can achieve for our patients. Managed care bars this right. Confidentiality, that allows leaks, bars this right.
Second, is the right to equal access, real equal access to adequate and appropriate treatment and services. Managed care and public policies are not providing equal access even in those states that have parity.
Third, is the right to live in this nation’s communities. Just as this nation has correctly spent a great deal of money changing our sidewalks so that those limited to wheelchairs can live in our communities, so the states should provide the social, housing, education, job support that would make it possible for most of the psychiatrically disabled to live in our communities.
Dorothea Dix had positive, not negative, goals. The rights for psychiatrically ill I have stated are what we are for, not what we are against.
Like each of you, I have had major opportunities to express outrage. When it became my turn to direct Saint Elizabeths, there had been a 120-year tradition of patients working without being paid. Staffing was inadequate. The buildings were unsafe. We forced NIMH to find one million dollars to provide a pay role for patients. We forced Department of Health and Human Services to give us funding for four hundred additional clinicians. Through testifying in Congress we received $65,000,000 to make the buildings safe. These increases in resources remain the largest in Saint Elizabeths’ 144-year history.
When the Director of NIMH attempted to make a major appointment that didn't meet equal employment values, I took him to a federal court, stopped him cold, and had a federal personnel policy’s loop hole closed for all future federal employees.
Incidentally, being outraged doesn’t necessarily make enemies. That NIMH Director and I have been friends before, during and since, and he has long thought I should be president of the APA.
To champion these three rights of the psychiatrically ill, we need to value every psychiatrist in this country as a potential soldier in the effort to achieve the rights of the psychiatrically ill, not value them for their dues. Unfortunately, too many respected members have resigned in frustration with our organization. Valuing members of an organization means the leadership being accountable to the members. Valuing the members means being a democratic organization. Instead our Board has become an oligarchy. I am going to list 8 signs that suggest the diagnosis of an oligarchy.
First, the fact that at the last two Board meetings more time was spent in secret meetings than in open meetings. When I become president, meetings will be far more open.
Second, the fact that the Board recently passed a budget document, and the Board members were admonished to say nothing about that document beyond a press release limited to a few facts that the Board apparently felt would put the Board in good light. When I become president, budget process and results will not be secret.
Third, the fact that when the Assembly’s motion asking the Board to record its votes reached the Board, many spoke against the idea. The Board vote was a tie. Harold Eist, as president, broke the tie and the motion passed. The Secretary, however, has not recorded the votes in the minutes. When I become president, votes will be taken and recorded.
Fourth, the fact that the APA’s expenditures on salaries are kept secret within the APA, even though they are public knowledge. If you ask, the IRS will tell you that in 1996, Mel Sabshin was compensated $258,000, and, in 1997, his last year, $1,631,882. That $1,631,000 may be justified. Even in the highly secretive business world, however, the stockholders are told about compensation. We should respect our members. When I become president, the members will know how their money is being spent. Moreover, sunshine will shrink some potential expenditures.
Fifth, is the fact that the Board wants us to endorse an amendment about which the Board has voted on a document about the transition governance, but that document is secret. When I become president, members will know the full details of any proposed amendments.
Sixth, is the fact that the Board wants the members of the APA to approve an amendment that would keep 27 of the 50 members on the Board for life. Some supporters of this amendment say it is not a problem because more than half of the 27 don’t attend the Board meetings. I’m not sure which is worse, having them on the Board for life or having most not taken their responsibilities seriously. I am opposed to any lifetime membership.
Seventh, is the fact that the APA President announced last July that the Board had already spent 8 hours on the past-president’s issue, and then they went ahead and spent another hour. They have spent more time on that issue than they have spent on any one of the three rights I have mentioned. When I become president, the Board will focus on the fate of patients, not focus ad nausea about the status of Board members.
Eighth is the fact that the APA is a huge, 1000+, patronage system. A top-down system. When I become president, subspecialty organizations will decide who represents their subspecialty and many other appointments will be by Areas selecting those who have well served their District Branch. We need to move from a patronage system to a representative and meritorious system.
The Assembly is more democratic that the Board. The Assembly can become more democratic, however, and hopefully the rapid progress in electronic equipment will soon allow the Assembly to record its votes.
Like most democracies, the Assembly is hard to admire, but, as Churchill said, bad as it is, democracy is better than any other system of governance. I believe in the democratic process and believe that the Assembly speaks for the members.
While much of what I will change as president is procedural and within the powers of the presidency, when it comes to policy changes I will write an Action paper. If APA leaders respect the members of the APA, they will take their proposals to the floor of the Assembly. Furthermore, to be effective, I will need your support. The most respectful and most effective way of obtaining your support is to come to Assembly with Actions for your approval. I will be the first president to do so.
I came into the Assembly in 1975 and have worked with Legault, Coleman, Starr, Sack, Kline, and Milowe and have had the help of Harold Eist and Rich Epstein to strive to express the wishes of American psychiatrists. Year after year, we have brought three to eight Actions to each Assembly, and the majority have passed. The APA has no better test of whether one has captured the wishes of American psychiatrists than to develop an Action paper that the Assembly adopts. I have passed that test as often as anyone.
Does the Board become democratic or remain an oligarchy? I want your support to become president to place a democratic organization behind the advocacy to achieve the three rights for the psychiatrically ill so that the psychiatrically ill in this country are not left in pain, not left disabled, not left in jail.
1. Initiated Action Paper calling for the APA to support the President’s Medicare expansion proposal; and further, to continue to champion the removal of Medicare’s undesirable procedures, policies, and discriminations. With Larry Kline and Larry Sack.
2. Initiated Action Paper calling for the APA to approve the development of a strategy to increase the access of people with Alzheimer’s Disorder and other dementias to psychiatrists. With Larry Kline and Larry Sack.
3. Initiated Action Paper to have the APA develop procedures and policies in order to open a dialog with the criminal justice system that would lead to identifying those who have been incarcerate as a result of mental illness and averting future inappropriate incarceration. With Larry Kline and Larry Sack.
4. Initiated Action Paper calling for the APA to support the Health Care for Working Families Act. With Larry Kline and Larry Sack.
5. Initiated Action Paper calling for the Board to reconsider its action of October on the issue of the development of a caucus of psychiatrists working in jails and prisons; and further, the Assembly has a committee - the Committee on Public and Community Psychiatry - that represents psychiatrists in all public settings. Since jails and prisons fall within the purview of public psychiatry, the Assembly should ensure representation on the Assembly Committee on Public and Community Psychiatry by member[s] who represent the interests of psychiatrists working in jails and prisons. With Larry Kline and Larry Sack.
1. Initiated Action Paper calling for Recorder of Assembly to replace the Assembly Executive Committee as the official monitor of the progress of actions that has passed the Assembly, 1997.
2. Initiated Action Paper calling for the APA’s Research Council to explore the concept that all NIH funded research using placebo controls should describe the physician-patient relationship is sufficient detail to enhance our understanding of that relationship, passed, 1997
3. Initiated Action Paper calling for reduced role of the Joint Reference Committee, 1996. Passed Assembly, but not the Board.
1. Incomplete, but included motion that APA’s Board of Trustees record their votes, take a role call when a motion was not passed unanimously. Became APA Board policy.
2. Initiated Action Paper on “have the APA adopt the policy of being opposed to ‘Hold Harmless” statements in managed care contracts for psychiatrist.” Passed both Assembly and Board of Trustees, 1996.
1. Lengths On Inpatient Stays for Anorexia Nervosa.
To publicize the plight of persons suffering anorexia nervosa who are unable to obtain medically necessary care, November, 1995. [Larry Kline primary author]
2. Managed Care Organization Which Refer Patients to Psychiatrists only for Diagnostic Evaluation and Pharmacologic Management and never for Psychotherapy. To implement a policy that psychiatrists be referred patients for psychotherapy as well as for diagnostic evaluation and pharmacologic management, November, 1995. Larry Kline and Larry Sack were primary authors.]
3. Standards for Psychiatric Office Patients Records and Records Inspections. To develop APA endorsed standards for psychiatric office records and records inspections, November, 1995. [Larry Kline was primary author].
4. Indications for Psychiatric Hospitalization. To establish a clinically sound standard for admission to inpatient treatment, November, 1995. [Larry Kline was primary author].
5. Profiteering in Health Care. Put the APA on record as condemning profiteering in all forms of health care, November, 1995. [Larry Sack and Larry Kline were primary authors].
6. Indications For Outpatient Psychiatric Treatment Which Is Not Short Term And Crisis Oriented. To establish a clinically sound standard for outpatient treatment which is not short term and crisis oriented, November, 1995. [Larry Sack and Larry Kline were primary authors.]
7. Initiated Action Paper on: “With the new Medical Directorship, information about the budget of the APA should be an open one including the salaries and bonuses of the staff.” Passed Assembly and Board of Trustees, 1995.
DSM-IV published. As member of Multiaxial Issues Work Shop, moved to abolish Multiaxial system. Motion failed after decision made to include statement in DSM-IV that it was OK to use a non-axial system and to have Peele include some non-axial examples in the text [page 37 of DSM-IV-TR].
1. Initiated Action Paper on the APA’s position relative to Health Care Reform that passed, 71 to 43, the Assembly in May 1993 calling for:
• the goal of non discrimination includes “psychotherapy” • the goal of non discrimination includes for all medically necessary hospital treatment • the goal of non discrimination includes advocating for equal coverage of the public hospital with the private • APA will oppose use of persons unlicensed in the state being used as managed care reviewers. First Three passed Board of Trustees in July, 1993.
2. Initiated with Dr. Monica Miles, Action Paper calling for exploration of psychiatry being a Primary Care Specialty or having primary care functions, passed Assembly, 61 to 53.
3. Initiated with subsequent submission by Larry Kline, Action Paper calling for “Disseminating Data that Demonstrate the Feasibility and Cost Effectiveness of Delivering Medical Psychotherapy as Part of Comprehensive Psychiatric Services,” passed Assembly November, 1993.
4. Initiated Action Paper with Paul Chodoff calling for Ethics Committee to study impact of APA's Ethical Standards, passed Assembly in May 1993.
Involved in development of DSM-IIIR [Work Group to Revise DSM-III; Vice-Chair, Committee to Review DSM-IIIR of the Board and Assembly; Advisory Committee on Organic Disorders; Multiaxial System advisory committee]. Was one of the initiators to remove “ego-dystonic homosexuality.”
Report of the Speaker Being a Lighthouse
It was midnight and Admiral Muchpower decided to visit the bridge of his aircraft carrier, which was moving westward at 15 knots. Upon arriving at the bridge, he saw a light ahead. He ordered the signalman to flash this message: “Please change your course 5 degrees south.” The reply was, “Please change your course 5 degrees north.” The light did not change course. Annoyed, the Admiral sent, “Change your course 5 degrees south, this is Admiral Muchpower.” Reply: “Change your course 5 degrees north, this is Petty Officer Smith.” Very annoyed, the Admiral sent, “Change your course 5 degrees south, this is a U.S. Navy aircraft carrier.” Reply: “Change your course 5 degrees north; this is a U.S. Coast Guard lighthouse.”
Given the apparent overwhelming nature of the economic and political forces influencing the access to adequate care and treatment of the psychiatrically ill today, how does an organization of 33,000 remain the lighthouse that those with much power will recognize? Recent Assembly actions provide direction. Being a lighthouse requires a moral foundation, a solid organization of membership resources, a beam consistent with the rest of medicine, and a focus on standards of psychiatric treatment. I want to address each of these issues and speak to the Assembly’s role in these issues.
The Assembly’s 1986 request that APA explore the feasibility of establishing an advocacy office highlights one of APA’s moral obligations. Avoiding advocacy leads to losing responsibility for patients-and losing professional autonomy.
Advocacy can be organized around the three meanings of “patient rights”: a right to independence, a right to equality of access to opportunities with those who are not psychiatrically ill, and a right to entitlements that are unique to the needs of the psychiatrically ill (1).
Independence means each patient has the right to attain the maximum degree of freedom from his or her psychiatric illness and the consequences of that illness.
Equality means that the psychiatrically ill have the same opportunities for access to treatment and services in our communities and that the various forms of discrimination against the psychiatrically ill be eliminated.
Foremost among these efforts is abolition of discrimination in health insurance and managed care settings. Very disturbing is what has happened to the Blue Cross-Blue Shield health insurance plan for federal employees. That flagship program has had a 43% decrease since the 1970s in the total proportion of benefits going to psychiatric treatment (R.J. Luehrs, former Executive Director, Operations, Blue Cross and Blue Shield Association Federal Employees Plan).
Very disturbing also are the discriminations in managed care settings. Several years ago, prognosticators were telling us that if we wanted to treat the psychiatrically ill, we had best join health maintenance organizations (HMOs). Now it seems HMOs may be the last places to join if we want to treat the psychiatrically ill. (2,3)
The Assembly led the way by asking in October 1982 that the goal of APA’s government relations be nondiscrimination. In pursuing nondiscrimination, two other terms sometimes intrude and cause confusion. One term is “parity.” Parity’s focus is on “producers” - milk producers and so forth. Parity lacks the focus of the Assembly’s goal of nondiscrimination for patients. The other problem term is “mandates.” The Assembly endorses steps directed at decreasing discriminations. Thus, the perspective of the Assembly is that there are good mandates or bad mandates, depending on whether the mandate seems to decrease discrimination or preserve discrimination.
The third meaning of patient rights-”entitlements”-is basic. As the blind need access to Braille and as the deaf need access to hand-signing interpreters, so the chronically disabled psychiatrically ill need access to educational, occupational, and social supports to be part of our society. In advocating entitlements, especially the more expensive entitlements, we owe the public empirical evidence that a specific entitlement achieves its purpose. Too often we have only been able to offer rationales. Each entitlement needs to be approached with the same regard that we use in approaching treatment modalities (4). Thus, we need to state the indications, contraindications, cautions, and conditions of use of each entitlement. We need to express public psychiatric policy in medical terms. We need to move from dogma and debate to data in clarifying what an entitlement will achieve, for whom, and at what cost.
In conceptualizing entitlements, it is essential that we first clarify the importance of achieving equality of access. Adequate psychiatric treatment narrows the need for entitlements. In calling on APA in 1979 and 1985 to adopt the recommendations of The ChronicMental Patient (5) and The Homeless Mentally Ill, the Assembly took a positive stance on the many entitlements suggested in those two APA publications. An example may help clarify this point, so I will select an entitlement, namely asylum (7-9), that has been of personal interest to me for more than a decade and is one of the entitlements advocated in The Homeless Mentally Ill. An asylum for the chronically disabled or the chronically dangerous can be expensive. Theoretically, for a single patient who becomes permanently disabled or dangerous in his or her late teens in the District of Columbia, the lifetime cost of care and treatment could be $1-$5 million in today’s dollars. Thus, at Saint Elizabeths, in developing the Asylum Community, we established narrow indications. Our criteria included the proviso that we not use this option until all substantial therapeutic approaches have been exhausted. When treatment is denied or disallowed, this can lead to an abuse of asylum. When treatment is denied or limited, there is premature use of non-therapeutic substitutions. Discrimination against the psychiatrically ill in insurance and managed care systems thus has the potential of leading to overuse of asylum and other entitlements.
The Assembly has taken the lead in recent years in stating the need for entitlements, but the Assembly’s emphasis on nondiscrimination reminds us that entitlement needs cannot be adequately delineated and protected while discriminations against the psychiatrically ill continue to force an inappropriate use of entitlement resources in lieu of adequate treatment. The overriding issue is the need to abolish discriminations against the mentally ill. We must abolish these discriminations!
“Unity Amidst Diversity” was Dr. Nadelson’s presidential theme for the 1986 annual meeting. To marshal the energies of this nation’s estimated 39,000 psychiatrists and psychiatric residents require that APA be receptive to diverse views and interests. It is a tribute to APA leaders, especially Dr. Sabshin, that more than 80% of these 39,000 are APA members. Still, the fact that there are about 65 national psychiatric organizations outside APA (Appendix 1) raises questions. Why are so many resources and so much of psychiatrists’ energy going to organizations outside APA? Are there clinical, economic, educational, political, or social needs that APA cannot meet? I believe, with a few exceptions, that is doubtful. These organizations represent subspecialization interests. Last year we categorized subspecialists by identifying particular aspects of psychiatrists or their work as follows (10):
1. A personal characteristic of the psychiatrist (age; sex; race; national origin; educational site or level; sexual preference).
2. The function (administration; clinical psychiatry; consultation and liaison; forensic psychiatry; occupational psychiatry; prevention public health; research; academic psychiatry).
3. The employer (community mental health center; correctional institution; federal government; HMO; military; public sector; general hospital; private practice).
4. The treatment site (office/outpatient/clinic/ambulatory care; day or partial hospitalization; inpatient or hospital psychiatry).
5. A body of knowledge or a treatment procedure (ECT; milieu therapy; psychoanalysis; psychopharmacology; psychotherapy; rehabilitation).
6. A personal characteristic of the patients served (age, such as old age; ethnic or racial characteristic, such as Hispanic origin; non-psychiatric handicap, such as deafness; geographic area, such as Casper, Wyoming; specific psychiatric illness, such as affective disorder).
Advocacy support is easier if our organization parallels identified patient organizations (10). Gains in recent years in the public support of treatment of Alzheimer’s disease, alcoholism, and mental retardations are examples.
Relation With Subspecialization Groups
In relating to subspecialized groups, four options occur to me:
1) ignore the subspecialty group;
2) develop liaison with the subspecialized group;
3) affiliate with the subspecialized group and allow it a place within our governance, such as medical specialty organizations’ relations within the AMA; or
4) assimilate the subspecialty group and give it a role in the governance.
Being a lighthouse requires a unified beam. Ignoring or having liaison hardly assures unity. The affiliation model as represented by the AMA seems quite inferior to assimilation. As for the organizations participating in the governance of the AMA, many, sometimes even a majority, of an organization’s members are not members of the AMA. This form of governance of the AMA seems regrettable, but it may be too late for the AMA to achieve assimilation. It is not too late for APA to have assimilation as one of its organizational goals.
A strategy of assimilation raises governance issues. Until the 1970s elected representation in APA was nationally or geographically defined. In the 1970s the Assembly added to its bylaws minority representation, which included an important requirement: “potential patients and other citizens with similar minority characteristics.” In the 1980s we have added a specific educational level (residents). In organizing for advocacy, we face the question of whether elected geographic representation, minority representation, and resident representation are adequate to provide a unity for advocacy. Recent trends suggest this is not adequate. Many would submit we have lost or are losing large patient groupings such as mental retardation, Alzheimer’s disease, and substance abuse (including alcoholism).
Especially relevant today, of course, is the huge expansion of the care and treatment of substance abusers. Symbolizing the recent expansion was a 346% increase from 1978 to 1984 in private substance abuse units in this country (S. Frazier, personal communication, Sept. 5, 1986). As the war on substance abuse unfolds, it does not appear our present representation is adequate to advocate effectively the need for psychiatrists in the care and treatment of substance abusers, maybe the fastest growing field of the 1980s. At the end of this decade, will it be concluded that APA lost this area, one that is so large and of such concern to the public, partly because APA was never organized to advocate the use of psychiatrists in evaluation and treatment of these disorders?
Let’s assume that my subspecialty is substance abusers. Do I join (and pay dues to) a group outside APA to represent my belief that psychiatric knowledge and skills should be part of every substance abuser’s evaluation and treatment? Do I join an outside group to have a voice in these issues? Do I join an outside group to attend educational meetings and obtain relevant journals? Within APA, do I believe it is satisfactory to be a possible appointee to APA’s Committee on Drug Abuse, which averages one vacancy a year? Or does APA create a component that I can join (and pay dues to) that has its own elected leaders, a substance abuse newsletter and journal, and a substance abuse educational track and business meeting within the APA annual meeting? Assimilation within APA of my subspecialty seems to be in my interest-and in the rest of psychiatry’s interest.
“Medicine in Psychiatry: Psychiatry in Medicine,” Dr. Pasnau’s theme for this year, is rich with implications, one of which is our relationship with the rest of medicine. Some advocacy issues are not uniquely our issues but medicine’s issues, e.g., patient-centered ethics, autonomy of practice, and tort reform. As we strive to increase access for the psychiatrically ill to adequate psychiatric treatment, our reason for advocacy, we face issues within medicine, including the following:
1 . Counselors, ministers, nurses, psychologists, social workers, and others are asking to be treated as independent health providers. This is an issue not limited to psychiatrists. The decision to support or oppose the independent private practice of other disciplines is a medical issue. Any APA position on this topic has to be pursued within medicine as a whole.
2. Since non-psychiatric physicians treat more mental illness than do psychiatrists, social workers, psychologists, and nurses combined (17), since mentally ill patients are often inadequately treated by non-psychiatric practitioners, and since prospective payment arrangements drive even more of the treatment to primary physicians and away from specialists such as psychiatrists, our interest inincreasing the access of people when they are mentally ill to adequatepsychiatric treatment requires that our primary collaborative focusbe with medical colleagues. The Joint Commission on Public Affairs’ Physician Awareness Campaign touches this need. The Assembly’s actions in May 1978 and last November to allow the terms “psychiatric physician” and “psychiatric medicine” and to encourage APA leaders to be members of the AMA would seem to be useful additional aspects in assisting this nation’s large number of patients to receive adequate psychiatric treatment. In searching for collaboration in advocating the goal of achieving adequate psychiatric treatment for the psychiatrically ill, we must start by establishing understandings with our medical colleagues. We must do this at all levels: nationally, locally, and individually.
Speaking to Standards
A profession without standards is not a “profession.” All professions, by definition, have standards (12, p. 202). Professional standards may address our training and thus define ourselves. Professional standards may address what is adequate psychiatric treatment and thus define what we do. Until we make additional progress in defining adequate treatment, our advocacy goals will be hampered.
In 1985 and in 1986 the controversy about publication of an APA treatment manual clouded discussions about the need to address the issue of standards in psychiatry. The November 1 986 motion by the Assembly to have the “not official APA policy” disclaimer and to allow the treatment book to be published as a task force report clears the table for a meaningful discussion of standards.
The Assembly has spoken frequently to standards of care and treatment. There have been a series of actions over the past decade about the standards of the Joint Commission on Accreditation of Hospitals (JCAH) and standards for community mental health centers. The Assembly will likely continue to look for opportunities to define “adequate” psychiatric care and treatment. Our ability to advocate is going to depend on specific definitions and identifiable characteristics for “adequate.”
The potency of JCAH is a reminder that our aircraft-carrier-lighthouse analogy is not just a funny story. Speaking very generally, standards in today’s society are “a force so pervasive as to shape the world and control systematically the content and process of human life” (12, pp. 227-228). It is in standard setting that a profession “can have the most unequivocal influence” (12, p. 204). Dr. George Pollock’s theme for the 1988 annual meeting will be “Opportunities and Challenges for Psychiatrists and Psychiatry: 1988-2000.” There will be no bigger opportunity and challenge than the issues surrounding standards. The Assembly’s Role
Of the 1,205 national APA leaders listed in the 1986-1987 APA directory, 82% are selected by the President or by the Speaker. Of the 2 1 9 who have been elected to their positions by APA members, 91% are in the Assembly!
Concerns about the governance of APA activities have come from the Assembly. An increase in the number of elected rather than selected leaders would begin to answer the need for more APA activities to be overseen by elected leaders.
Such an increase in elected leaders would also be part of the strategy for assimilating subspecialized interests within APA. The Assembly will need to decide whether it favors more elected APA leaders. If so, does it want those elected leaders on the floor of the Assembly or in other components?
The decision in November 1986 to have voting representatives of residents in the Assembly leaves the Assembly with no criteria for Assembly membership. We could be on the brink of a run of motions for admission to the Assembly. The Assembly may want to pause before adding members until APA has come to terms with the place of elected leaders in APA and until the Assembly establishes its membership criteria.
To be a lighthouse in the fog of prejudice and ignorance surrounding care for people when they are mentally ill requires an intense light, one intense enough to guide the enormous economic and political forces affecting access to adequate psychiatric treatment. To provide this guidance, we must deepen our moral roots, unify our voice, strengthen our ties with the rest of medicine, and set reasonable and comprehensible standards. In the past, the Assembly has led in addressing these issues. Knowing the members who constitute the Assembly, I am confident that the Assembly will continue to develop the foundation, strengthen the unity, and intensify the beam of the lighthouse our profession and our patients so desperately need.
Ms. Grace-Marie Arnett, Dr. Roy Coleman, Dr. Seymour Gers, Dr. Julius Hoffman, and Dr. Dorothy Starr made suggestions that improved this report.
1. Peele R, Palmer RR: Patient rights and patient chronicity. J Psychiatry and the Law, Spring 1980, pp 59-71
2. Backus YP: HMOs: not always the best medicine. Hosp Community Psychiatry 1987; 38:229
3. Flinn DE, McMahon TC, Collins MF: Health maintenance organizations and their implications for psychiatry. Hosp Community Psychiatry 1987; 38:255-263
4. Wyatt RJ, DeRenzo EG: Scienceless to homeless (editorial). Science 1986; 234:1309 5. Talbott JA (ed): The Chronic Mental Patient: Problems, Solutions, and Recommendations for a Public Policy. Washington, DC, American Psychiatric Association, 1978, pp 209-220
6. Lamb HR (ed): The Homeless Mentally Ill: A Task Force Report of the American Psychiatric Association. Washington, DC, APA, 1984, pp 5-9
7. Peele R, Luisada PV, Lucas MJ, et al: Asylums revisited. Am J Psychiatry 1977; 134:1077-1081
8. Peele R: Will we always need asylums? Washington Post, Oct 31, 1983, p C-i
9. Lamb HR, Peele R: The need for continuing asylum/sanctuary. Hosp Community Psychiatry 1984; 3S:798-802
10. Peele R: Report of the Speaker-Elect. Am J Psychiatry 1986; 143: i348-13S3
1 1. Regier DA, Goldberg ID, Taube CA: The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978; 35:685-693
12. Friedson E: Professional Powers: A Study of the Institutionalization of Formal Knowledge. Chicago, University of Chicago Press, 1986
APPENDIX 1. Psychiatric Organizations Outside APA
The following are 64 psychiatric organizations outside APA. This listing is not necessarily complete. Although an attempt was made to limit the list to organizations considered primarily for psychiatrists, organizations in which non-psychiatric members are regarded as essential may have inadvertently been included.
Academy of Psychosomatic Medicine
Academy of Sleep Disorders Medicine
American Academy of Child and Adolescent Psychiatry (APA has liaison)
American Academy of Clinical Psychiatrists
American Academy of Psychiatrists in Alcoholism and the Addictions
American Academy of Psychiatry and the Law (some local subcomponents)
American Academy of Psychoanalysis (APA has liaison)
American Association for Geriatric Psychiatry (APA has liaison)
American Association for Psychiatric Training of Medical Students
American Association for Social Psychiatry
American Association of Chairmen of Departments of Psychiatry
American Association of Community Mental Health Center Psychiatrists
American Association of Directors of Psychiatric Residency Training, Inc.
American Association of General Hospital Psychiatrists
American Association of Psychiatric Administrators (some local subcomponents)
American Association of Psychiatrists From India
American Board of Forensic Psychiatry, Inc.
American College of Neuropsychopharmacology
American College of Psychiatrists
American College of Psychoanalysts
American College of Psychosocial Research
American Neuropsychiatric Association
American Psychoanalytic Association (many local subcomponents)
American Psychopathological Association
American Psychosomatic Society
American Society for Adolescent Psychiatry (many local subcomponents)
American Society of Hispanic Psychiatrists
American Society of Psychoanalytic Physicians
Association for Academic Psychiatry
Association for the Advancement of Psychoanalysis
Association for Clinical Psychosocial Research
Association for Mental Health Affiliation With Israel
Association for Research in Nervous and Mental Disease, Inc.
Association of Child Psychoanalysts
Association of Directors of Medical Student Education in Psychiatry
Association of Gay and Lesbian Psychiatrists
Association of Korean American Psychiatrists
Association of Navy Psychiatrists
Association of Sleep Disorders
Association of Women Psychiatrists
Black Psychiatrists in America
Chinese American Psychiatrists Association
Clinical Sleep Society
Eastern Psychiatric Research Association
Federation of American Psychiatry
Group for the Advancement of Psychiatry
Group of Concerned Psychiatrists
Japanese American Psychiatric Association
National Association of Veterans Administration Chiefs of Psychiatry
National Guild of Catholic Psychiatrists
Pakistan Psychiatric Society
Philippine Psychiatrists of America
Phobia Society of America
Psychiatric Research Society
Society for Psychiatric Treatment Research
Society of Biological Psychiatry
Society of Iranian Psychiatrists in North America
Society of Military Psychiatrists
Society of Professors of Child Psychiatry
Society of United States Air Force Psychiatrists
Southern Psychiatric Association
Turkish-American Neuropsychiatric Association
The Goal of APA Relative to Private and Publicly Supported Health Insurance Programs, Assembly, October 29-31, 1982. [with Roy Coleman] 2. Caucus Representation, The Assembly Recognizes Homosexual- Identified Psychiatrists as An Under-Represented Group, 1982. [with WPS gay and lesbian community]
Initiated Action Paper that became APA policy: "Principle that the effectiveness of relief of pain in terminal cancer patients should take priority over a concern about ‘addiction’ of the terminal cancer patient and should take priority over concern about medication diversion to addicts." Subsequently, it became policy - American Medical Association and American Orthopsychiatric Association, 1979, but later the AMA changed its mind and rejected this proposal. Quoted in the U.S. Congress periodically by Congressman Waxman in the 1980s.
Initiated Action Paper that became APA policy: patients who must be treated involuntarily should only be committed to JCAH Accredited institutions, i.e. patients should never be committed to an unaccredited institution, 1978.