The American Academy of Psychoanalysis and Dynamic Psychiatry – 75 Years from Now

The following is a shortened edited version of the Presidential Address which I gave at the 2014 Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry held in New York May 2014.  This article in edited form will also appear in the next issue of the The Forum, a magazine published by the American Academy of Psychoanalysis and Dynamic Psychiatry , Any comments are welcome at the end of this article

 

The American Academy of Psychoanalysis and Dynamic Psychiatry 75 Years From Today

Michae Blumenfield, M.D.

President 2012-2014

 2089

The theme of this meeting has been 75 Years After Freud and my talk in closing this meeting is the Academy 75 Years from today

Screen Shot 2014-07-14 at 12.27.04 AMNow let us look 75 years into the future – The year is 2089. I have a fantasy that the President of our organization will be my grandson Obi, who recently turned 5 years old now but at that time he will be 80 years old….. in the PRIME OF HIS LIFE. Obi’s life expectancy is to be 79-86 by projections today but many believe with scientific advances that we will have, it will be much longer. In fact,  in an article in the Journal of Anti Aging Medicine a few years ago, 60 gerontologists from leading universities all over the world were asked for estimates regarding the development of future life expectancy for a person born in the year 2100 – 86 years from now. The median prediction was 100 years whereas the mean was 292- since 3 people predicted over 1000 years. – showing that there were some Death deniers.

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I am doing a project where I am recording an audio interview with the past Presidents of the Academy and I had the pleasure of doing interviews with Milt Zaproloupus and Mary Ann Eckhardt both over 100 year old and going strong

So perhaps 80 year old Obi in his prime will be President of the Academy and he will be standing here or perhaps he will be speaking to us via Hologram .

One of my son’s is a TV producer and he said to me why don’t you do a live demonstration and project yourself into the lecture hall. I looked into this technology which is definitely available but now costs $100,000 so I thought I would save the Academy some money and let’s wait until the cost comes down. Holographs or not – In 75 years from now our President will be here surrounded by large screens where perhaps simultaneous gatherings will be taking  place all over the world in lecture halls or in their offices watching and participating in this meeting

 I believe it is fair to say that we will be an international organization. This year during my presidency we changed the international dues schedule based on World Bank calculations so our international colleagues can afford to join. Those of you teaching in the CAPA (Chinese American Psychoanalytic Alliance) know about the nascent but growing interest in psychodynamics in China which will be full grown in 75 years. In fact I predict before 75 years we will change our name from the American Academy of Psychoanalysis and Dynamic psychiatric to just the Academy of Psychoanalysis & Dynamic Psychiatry. I believe we will still be aligned with the APA and American Psychiatry …but if we follow the trends of international psychiatry so we can also be aligned with international psychiatrists who value psychodynamic psychiatry.

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We are in the midst of a technology revolution that clearly affects the way we communicate with each other. Many of us are doing therapy using Skype or newer technology. I am treating a Chinese psychiatrist in China via this video technology 2x/week as part of the CAPA program Chinese American Psychoanalytic Alliance. I have treated college students who when they left to go to out of town college continued seeing me via Skype . Many of you are doing similar things

In 75 years from now we will also be teaching psychodynamic psychiatry via the latest technology. Many of you are already teaching and supervising via Skype or similar technology. I have had the exciting experience of teaching a class by SKYPE in psychoanalytic technique to Chinese students simultaneously in three different cities in China for CAPA

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My colleague Jim Strain and I have set up a program where we have offered long distance courses to 3rd world countries and have taught psychosomatic medicine via Skype or similar technology in Colombia South American and Rwanda.

It is also interesting to consider what role will the Academy play in providing teaching courses in psychoanalytic and psychodynamic theory and treatment in the United States. While at present this is being provided by the residency programs and psychoanalytic Institutes, there are many changes going on now in the systems of post graduate education. It may very well be that in future years the Academy will take a very important role in providing the latest teaching of psychodynamic psychiatry and will do much of it using the latest techniques delivering classes and perhaps supervision directly. 

Screen Shot 2014-07-14 at 12.49.32 AM After I prepared this talk, I opened the NY Times and I learned that 3D Virtual Reality will be here very shortly. Facebook has paid 2 Billion dollars for a Virtual Reality Company that will give people the illusion that they are physically present in a digital world. The translation to Long Distance Learning and Therapy sessions won’t be far behind

But the BIG question is what will our theory and therapy look like in the distant future???? 

 In order to anticipate the role of psychodynamic and psychoanalytic therapy in 75 years from now we have to try to anticipate what will the state of the art of science, medicine and general psychiatry?? Let’s remember how far psychiatry, medicine and modern technology has come in the past 75 years

 Although the effects of penicillin was discovered a few years earlier it wasn’t until 1939- 75 years ago that a usable product was developed which we would say was the first antibiotic

 In 1938 76 years ago Cerletti and Bini introduced ECT therapy

75 years ago – it would be another 10 years until Lithium therapy for bipolar was discovered by John Cade

 75 years ago it would be another 12 years before chlorpromazine the first antipsychotic medication would be introduced.

Forget about computers 75 years ago regular TV was just started in the US Bill Gates father was 14 years old and his mother was 10 years old

 We know scientific advances occur exponentially – meaning that they will occur much faster in the next 75 years then they did the previous 75 years ago.

So what clues do we have what psychiatry will be like in 75 years from now? And what predictions can we make?

 

Screen Shot 2014-07-14 at 1.00.18 AMWe will have a much more complete understanding of the genetic and biological nature of Major Depression, Schizophrenia, Bipolar Disorders, PTSD and Dementia as well as entire new sophisticated methods of treating them and preventing much of the symptoms manifestations. Just looking at the journals which come across my desk in one recent month I noted:

 The role Apolipoprotein e-4 allele gene and depressive symptoms as well as the relationship to cognitive disorders

 Psychosocial risk factors associated with elevated plasma peptide endothelium

 Genetics predicators of lithium response

 Relationship between heart disease and depression

Relationship between depression and diabetes

 Role of inflammation and psychiatric symptoms

 The Role of Transcranial Stimulation on Depressive Disorders

 Neuroimaging differences in patients with Borderline Personality Disorder

 You also may have seen a recent article the Academy Journal by Michael Stone which discussed Borderline personality related to hyper-reactivity of the Limbic System

I believe that it is fair to say that in 75 years from today, modern medicine will have extremely effective medications, injections of genetic material, brain stimulation , possibly even some type of surgery as well as techniques we have never heard of that will be effective in eliminating, controlling and preventing so much the psychiatric manifestations that we see today in our psychiatric practice. Treatment will be complicated and will require not only a understanding of the state of the art science and medicine but an understanding of human behavior and interactions. Therefore they will still be best treated by physicians who are especially trained in medicine as well as in human behavior and interaction by which I mean psychiatric specialists. Of course it is possible that some of these treatments will be relative simple and will not require specialists and many conditions may be treated by general medical physicians as they often are today.

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However- No matter how effective these treatments are, they won’t be able to eliminate the effect of human interaction especially during child development on personality development, conflictual feelings such as love, hate, guilt, empathy, object choice, positive and negative identifications, competitiveness, passiveness, creativity adaptation, maladaptation, happiness and sadness, fulfillment and lack of fulfillment.

I believe that EVIDENCE BASED Research will continue to accumulate which will show that the state of the art intensive psychodynamic psychotherapy undertaken in adulthood will be the most effective therapeutic method to bring about an emotionally full filling life. It will become known and accepted that the previously mentioned biological based treatments although immensely successful in treating major depression, OCD, bipolar, PTSD, panic disorder, perhaps social phobia, hopefully Schizophrenia , hopefully various forms of autism WILL NOT be able to address the effects of human interaction, thoughts and fantasies on the developing personality nor on the ultimate satisfaction with self and relationships and with one’s place in the world BUT a meaningful modern psychodynamic therapy will do so.

Screen Shot 2014-07-14 at 1.09.13 AM I believe evidence based research will show that biological based treatments mentioned previously will be extremely effective in eliminating biological and genetic psychiatric conditions and may very well be able to mitigate the emotional response to relationship issues, the emotional response to loss self esteem, PTSD   etc.  but certainly will not prevent these situations, external and internal which cause anxiety and depression,  from reoccurring. But I also believe that evidence based research will build on the existing body of knowledge that strongly suggests that meaningful intensive psychodynamic therapy – let us say for sake of discussion – about two years of psychodynamic treatment- will be the most effective for doing such and produce the best results for having the least debilitating symptoms and the opportunity for a more full filling life. In the past 10 years there has been an increasing amount of Evidence Based Research and discussion about the efficacy of Psychodynamic Therapy.

If science research shows this form of treatment is effective – People will want it and expect it! The questions remaining are who will do it, who will pay for it and how will it be different than the treatment we do today ??

 WHO WILL DO IT?

 Most likely the newer form of psychiatric treatment dealing with newer medications, genetic treatment, brain stimulation, other biological interventions yet to be conceived will be handled by physicians with special interest and training in human behavior – in other words, psychiatrists. As is often the case today- when psychotherapy is indicated the same doctor who is handling the biological forms of treatment if trained in psychotherapy is in the best position to do psychotherapy also . And that would be psychiatrists.

 Recently I have been interviewing past presidents of the Academy and asking them about the pathway of their career. Many of them as have I, were drawn into this field by first being fascinated with the working of the brain and then ultimately finding that, as challenging as the interventions we could do as physicians- it was even more interesting and rewarding to interact with patients and help them make meaningful changes through psychodynamic therapy. I can see his happening in the future, as generations of medical students will gravitate towards psychiatry as tremendous advances are made in treating mental conditions BUT ultimately they will realize that in addition to these interventions, the ultimate intervention for many people will be a period of intensive psychodynamic therapy.

 OF course as is the case now- the amount of people of wanting and needing psychodynamic psychotherapy will well exceed the number of psychiatrists available to perform this therapy. So there is every reason to believe that our colleagues in other mental health professions will continue to develop their skills in psychodynamic psychotherapy and will be performing this service as many of them are now.

 But let us imagine for a moment that time and research has determined that even after all the latest bio-genetic, brain stimulating, psychopharm forms of treatment, it has been clearly shown that an intensive psychodynamic therapy makes a big difference in people’s lives…… WHO WILL PAY FOR IT?

 

 In 75 years from now it seems clear that we will have some form universal health care program – maybe single payer or maybe more like the current health care that is being rolled out. IT most certainly will cover the biological, genetic, new medical brain stimulating, modern psychopharm treatment etc and if the scientific evidence is clear the people will demand and our universal health care could very well cover the 2 years of psychodynamic treatment I envision will be needed and wanted by so many people.  BUT what if evidence is there to prove that it is worth the time and money but the future political climate won’t allow it……?

Are there any other possibilities other than the rich shell it out and it becomes a treatment for the elite?  Remember we anticipate that median life span may very well be 100. People are going to living longer and be healthier longer. People will be working and living much longer than today.

Today, if we get a mortgage on our home it is for 20 or 30 years because people are expected to have that long of a productive working life.  That also was the basis for college and post graduate loans. It is worth it, if people correctly believe that psychodynamic therapy in their 20s 30s or 40s will make a difference in  the next 60 to 80 years of their lives,  but intensive psychodynamic therapy is going to cost them over a two year period maybe 5-10 % what their mortgage might be worth, why not take a mortgage on their psychological well being?  It could be attached to their mortgage which will will be 30 \or 40 year loans or have such loans institutionalized as education loans are these days especially since people may be living and working 10 or 15 years  longer then anyway.

How will Psychodynamic therapy be different than it is today?

 In order to anticipate this question , we would have to know how our lives will be different. How will childhood experiences be different? How will families be different ? How will technology impact our lives? What degree of poverty will IMPACT child development or lack of it . We are pretty sure that people are going to live longer and therefore people’s psychodynamics are going to be influenced by growing up in multigenerational families. There will be more great grandparents as well as grandparents interacting with the developing child . Perhaps more complicated patterns of competition and identification.

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What will we learn about children being raised by LGBT parents ?

 How will some of the assumptions and psychodynamic theory be changed and modified as we understand the kids developing in same sex families? Similarly, new understandings will emerge as in the future as  we have large numbers of people who are test tube babies perhaps genetically altered.

 I have observed and have written elsewhere on this blog about the tremendous drive of adopted, children or children raised by one biological parent to connect in some way with their both biological parents and their families whenever possible –even if adopted at birth or raised by one biological parent.

 

Screen Shot 2014-07-14 at 8.50.54 PMWe just now beginning to see the emergence of children who are digital natives. – meaning they have been using digital devices since they their earliest memory – often starting at age 2 and 3 . How will this play out in 75 years after 3 or 4 generations of this child raising component with even newer technology? How will their object relations, socializing patterns etc be impacted by this this technology in their lives?

 The latest statistics show that today 1/3 of people getting married have met online. So it is probably safe to assume in 2089 most serious relationships will be started online. Those of you who saw the movie HER realize that people are considering that it may be possible to establish a meaningful relationship with a so called person who is only a computerized program. Consider the psychodynamic implications of that!

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As therapists we are always interested in the patients emotional reactions to their thoughts and fantasies, especially when they occur during a therapy session. This is also an important aspect of transference and countertransference. We also use our own emotional reactions to what is being discussed in therapy. We know also that emotional reactions are accompanied by physiological changes throughout the body including changes in activities in various parts of the brain. All of these emotional responses   can occur before there is conscious awareness of the emotional reactions. I usually wear a fit bit on my wrist. This is wrist band which measures my heart rate and  number of steps I take – it also recognizes when I am sleeping. This is a first generation device. Similar devices are being developed that measure BP, pulse respiration rate and future devices are expected to have the capacity to measure cortisol levels and even other hormones including sexual arousal etc.  Perhaps a little band around the head would measure electrical activity of the brain.  The capacity to wirelessly project any measurements to a computer screen or projection screen already exist. So I can imagine that if the patient and the therapist each wore these devices we would have the ability to measure all these internal manifestations– ALL which could be observed by the therapist or the patient or possibly both during the therapy session.

 

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Obviously I really don’t know what is in store for our organization or the future of psychodynamic psychiatry and our profession. I do know that there is going to be lots of change. The tradition of our Academy has been one that respects the work done in the past but always has a willingness to consider new ideas. I hope we will continue to do this and that we will take steps to continually change our organization to meet the needs of our profession and embrace what is to come 75 years from now or 150 years after Freud AND BEYOND

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 Any comments are welcome below

 

 

 

 

 

 

 

 

 

 

 

 

Don’t Ask Don’t Tell-Not Psychiatric Topic

There are very few reasons that a psychiatry blog should discuss the recent change in policy of “Don’t Ask Don’t Tell.” After all, homosexuality is not a mental disorder and this is a case of righting a wrong of discrimination and an example of social justice. However, until 1973 American psychiatry considered homosexuality as a psychiatric diagnosis. The behind the scenes story of how the American Psychiatric Association reversed it’s official policy towards homosexuality is explained in an interview that Dr. Blumenfield had with Dr. Alfred M. Freedman who at the time was President of that organization. There are links to a transcript of that interview as well as a 3 part video broadcast on You-Tube or the entire audio of the interview on Shrinkpod which is a podcast.

Recently the US Congress passed a law and the President signed it repealing Don’t Ask Don’t Tell. We are told that it is on fast track for implementation. This means that that another discrimination barrier has been broken and gay Americans will be able to serve our country in the US military as other Americans may do.

There is very little reason that I should have to mention this in a psychiatry blog. After all homosexuality is not a mental disorder. Except perhaps for the fact that Don’t Ask Don’t Tell has caused a great deal of psychological pain to those who have had to hide their identify for fear of being kicked out of the military or  suffering other repercussions. This should not be minimized, but overall it is a discrimination issue and one of social justice but not a significant psychiatric one.

However, it was not always this way. Up until 1973, the psychiatric profession considered homosexuality a mental disorder. There was a DSM code for it. The predominant official psychiatric thinking included various theories how certain types of child rearing may have brought about this sexual orientation. Many psychiatrists believed that therapy could change homosexuality and bring about “normal heterosexuality.”

Obviously there were many psychiatrists and other mental health professionals who did not hold this view. There was an increasing amount of research which did not support it . In fact, some experts believed  that homosexuality was founded on genetic and  biological determinants. There was also a great deal of clinical experience which supported the idea that sexual orientation could not be altered by therapy.

There was an historic meeting of the American Psychiatric Association in 1973 where the APA Assembly debated and passed a position paper stating that homosexuality was not a disorder and an equally historic debate within the Board of Trustees which took this position. It then became the official position of the American Psychiatric Association which has been reflected in subsequent DSM publications.

A few years ago I was broadcasting a podcast on the Internet and I interviewed Alfred M. Freedman who was the President of the American Psychiatric Association in 1973. I asked him about the background and the details of this famous debate. It was a very revealing interview in which he shared with me the behind the scenes activities involved with this event. A transcript of this interview was reproduced in theJournal of Gay & Lesbian Mental Health 13(1) 2009.

Alfred M. Freedman, M.D.

Dr. Freedman was Chairman of the Department of Psychiatry of New York Medical College and hired me on the faculty there in 1980. He is now in his 90s living in Manhattan and still attends meetings of the APA.

I am pleased to be able to provide the links to this video interview which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.

First Anniversary of PsychiatryTalk.com

This blog is written to mark the first year of PsychiatryTalk.com being on the Internet. The readership has expanded from 25 hits/week to over 300 hits/day and it is still growing. A followup on the topics of several of the blogs written in the past year was reported.

I started PsychiatryTalk  a little more than one year ago and it has been an interesting experience for me. I have met people from around the world via this blog  and it is very gratifying to see the number of hits on it to continue to grow. Initially, there would be an average of 25 pages /day that were read. Now it is well over 300/day and growing. I originally thought that the blog would generate online discussion.  I was surprised to find that readers are reluctant to put comments on the blog itself, although many people will write to me or people whom I know will speak with me in person about various subjects about which I have written. I still encourage any readers to put comments directly on the blog in the comments section and they will be posted usually within a day or two. It is easier for me to write the blog every other week rather than weekly so I have recently switched to biweekly postings.

I thought that this might be a good time to report some follow-up on various blogs which I have written .

The first blog that I wrote on October 12, 2009 was Review of Fox TV Show Mental. It was a critique of a new television show  which was about a psychiatrist. In my opinion, the program lacked authenticity and missed the opportunity to depict psychiatry and mental illness in a realistic manner.The show was not renewed. There is an excellent program about a psychotherapist on  HBO titled In Treatment which  just began it’s third season. It stars Gabriel Byrne as Dr. Paul Weston who has weekly sessions with patients , including one with his own therapist. This is a scripted show and although the writing is quite good, it is fiction based on a similar Israeli TV show.  I believe that it  would be possible to develop a high quality reality tv show of an actual ongoing therapy which could not only show real therapy sessions but also allow for interesting discussion by experts. There would be some ethical considerations in doing it which but I believe could be overcome and it  could be done in a thoughtful manner.

The second blog on October 19th was titled When a Mother Kills Her Children. It was about post partum psychosis with a discussion of the Proposed bill before the US Congress tiltled the Melanie Stokes Mothers Act . I am pleased to say that in March of 2010 it was passed and signed by the President. This  legislation will establish a comprehensive federal commitment to combating postpartum depression through new research, education initiatives and voluntary support service programs.

In December 2009 I first wrote a blog Condolence for Soldier Suicide where I made the case that it was wrong for the President of the United States not to write a letter of condolence to the families of American soldiers who have died by suicide. Another blog was written on this subject in August  2010 titled We Can’t Avoid PTSD and Suicides . While the President has still not changed his policy, the Secretary of the Army has recently written to some of the families and expressed his regret on the death of the soldiers. Perhaps this may be a sign of things to come. I authored an Action Paper with Dr. Roger Peele of Washington D.C. requesting the Assembly of the American Psychiatric Association to ask the President to reconsider his policy on this issue. It was passed by the APA Assembly and also endorsed by the Board of Trustees of the APA . This makes it the policy of our 38,000 psychiatrists organization. In addition Mental Health America and the American Foundation for the  Prevention of Suicide has passed similar resolutions and also are in the process of gathering signature for a petition to  President Obama. I believe we are getting closer to this long over due recognition to the families of these soldiers .

Another important military issue  and human rights issue was discussed in the February 2010 blog titled Abolishing Don’t Ask Don’t Tell (DADT).  Polls have consistently shown a majority of the public supports letting gays serve, and Defense Secretary Robert Gates and top military commanders such as Admiral Mike Mullen have recently endorsed it. In September 56 Democratic senators voted for the defense authorization bill, which included DADT repeal, but the measure failed to achieve the 60 votes needed to overcome a Republican filibuster.  A recent study conducted by the Pentagon concluded that ” …while a repeal of DADT will likely in the short term bring out some limited and isolated disruption to unit cohesion and retention, we do not believe this disruption will be widespread or long-lasting, and can be adequately addressed. The report, based on responses from 115,000 service members and 44,266 spouses, includes interviews with former gay or lesbian service members, some of whom were discharged from the military under the “don’t ask, don’t tell” policy. Of those surveyed, 69 percent said they had served with a gay service member and 92 percent of those respondents said they were able to work together.Fifty to 55 percent of those surveyed said the repeal won’t have any effect, 15 to 20 percent said it would have a positive effect and 30 percent said the effect would be negative.The report went on to say that  “The reality is that there are gay men and lesbians already serving in today’s U.S. military and most service members recognize this,” the report states. “Much of the concern about open service is driven by misperceptions and stereotypes about what it would mean.”I still like the words of Barry Goldwater on this issue who said, ” It is not important if your are straight , just that you can shoot straight.”

When there was a proposal for a 39% hike in healthcare rates purposed in California by private insurance companies, I raised the question in a March 2010 blog titled  Stockholders Must Vote CEO Pay whether  there should be  law where stockholders,not Board of Directors of Compensation Committees, should be required to approve any compensation packages more than 200 times the minimum wage in the US. That controversy seems to have been revived just this past month when compensation at Wall Street firms was reported to be  expected to hit $144 million . A column in the Wall ll Street Journal raised the question I brought up that since the 2008 financial crisis profits remain 20% below the 2006 level while the pay at these firms rose an astonishing 23 % over that time frame,  shouldn’t the owners of these firms be the ones to decide if they want to spend their money raising the compensation of their executives. ?

The May 12th 2010  blog titled Autism & FragileX- New Treatment has become the most looked at blog of PsychiatryTalk of the year so far. In it,  two new research projects concerning Autism Spectrum Disorder and Fragile X Syndrome are briefly reviewed. In the first, a random controlled study of children with Autism Spectrum showed that the Early Start Denver Model showed statistically improvement over a control group in regard to intellectual development and adaptive behavior. In the second study, preliminary research showed that a new medication improved behavior associated with Fragile X Syndrome compared to the control group. There is also some belief that such medication would be effective with children with Autism Spectrum.  As a followup I don’t find any announcements of new breakthrough research. However, there is  a $211 million HHS-wide initiative that would invest an additional $1 billion over the next eight years in autism related activities, the NIH budget includes $141 million in FY 2010 for research into the causes of and treatments for autism spectrum disorders (ASD). The funded research will  include identifying biomarkers; improving ASD screening; establishing ASD registries; understanding genetic and environmental risk factors, as well as interactions between the immune and central nervous systems; and enhancing services that can help people with ASD across the lifespan.


Also in May I wrote two blogs addressing financial issues in the  American Psychiatric Association and they were Impact of APA Budget Cuts and  Increase APA Budget $1.5 Miilion. In the the former I discussed the expected impact of the cuts on the APA Assembly and APA Components particularly the Communications Committee and the Disaster Committee. In the second blog I outlined several specific suggestions how I felt that the APA could gain this large increase in it’s budget. Certainly the APA continues as a very vigorous organization representing 38,000 psychiatrist and speaking out on important issues concerning mental health. It is still too early to determine if the cutbacks will seriously hinder it in it’s effectiveness. I understand that some of my suggestions are being considered by some of the leadership but as far as I know no steps have been taken to implement any of them

In a July 14th blog titled I would Like to Thank My Psychiatrist It was stated that Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is was noted to be  example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment. My colleague Bill Arroyo informed me that Artest was mistaken in that his therapist was not a psychiatrist but another mental health professional. While I appreciate the correction, the changing attitudes towards discussing therapy still  holds and is a good trend.

Last month I wrote my first blog on Miners in Chile anticipating any psychological issues that people who have gone through  a traumatic event may experience. As the miners began to emerge from the successful rescue efforts asecond blog was written in conjunction with a blog that I wrote for  CNN.com which I suggest that in this situation I believe that resiliency will be the default and most if not all of these miners will not have any long lasting psychological effects. In fact this brush with death may end up being a positive experience for them . It is obviously too early to tell  but it is very gratifying to see the good feeling around the world for these miners. However, just recently  29 miners  died in an explosion in New Zealand and we are reminded how such tragedies occur all the time and so cause great mental anguish for so many people. In this regard still another report of a recent tragedy caught my eye and that was the traumatic event in Cambodia where more  more than 378 people died and hundreds more were injured in a stampede at the end of the annual Water Festival late Monday in Phnom Penh. So many of these victims  were young people , many in their teens. I hope that there are mental health professionals and others available to help the survivors, families and friends deal with their grief.

Needless to say, I am still enthused about continuing this blog. I do appreciate the growing readership and I would want to encourage each of you to feel free to comment directly on the blog with your own views are particular topics. Whenever I have had occasion to give a talk whether it has been at a national meeting, a Grand Rounds or even a local group, I am always very pleased if there are 25 people in the audience, as it is privilege to share my interest with others. So it becomes a special opportunity to use the Internet to reach much larger numbers throughout the world through this wonderful medium. Thank you all for your continued interest.

“I Would Like to Thank My Psychiatrist”

Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is an example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment.

Ron Artest

I was watching the TV of the celebration after the LA Lakers won the National Basketball Association championship by defeating the Boston Celtics.. A TV reporter thrust the microphone in front of ebullient LA player Ron Artest and asked him how he felt. Among the words that the elated basketball player blurted out on national television was  that he would  like to thank his  psychiatrist! He went on to say ” There is so much commotion going on in the playoffs. She helped me relax.” Granted this was not an Academy Award acceptance speech but is seemed quite unusual and remarkable that we are now hearing such a public acknowledgment.

Ron Artest has had outbursts of temper in the past  and one time a few years ago he ran into the stands and pummeled a fan. However, it is not known if his psychiatric treatment involved psychotherapy, psychopharmacology or some type of relaxation therapy concerning this crucial series. It is significant that more celebrities  in recent years have been comfortable in talking about  their own mental health issues and their treatment with psychiatrists and other mental health professionals.

Brooke Shield

When the Boston Celtics started winning their championships in the 1960’s  such a public statement was nearly unheard of. In 1972 a vice presidential candidate was revealed to have had depression with ECT treatment and he had to resign from the  ticket. While I suspect that  that a modern day politician could still not survive such a public revelation today, there has been a steady flow of celebrities who choose to talk about the their mental problems and psychiatric treatment without any discernible harm to their careers.

Carrie Fisher

For example this list would include Richard Dreyfus, Uma Thurman, Ben Stiller , Jim Carey, George Michael, Adam Ant, Sinead O’Connor, Wionnal Ryder with some becoming spokespersons for mental health issues and even appearing at psychiatric meetings such as Mike Wallace, Brooke Shield and Carrie Fisher.

These public revelations demonstrate how far we have come in the fight against stigma in regard to mental illness. Even the fictional roles of therapists on televsion have evolved. In the 1970s there was a situation comedy  where comedian Bob Newhart played a therapist. It was good for a lot of laughs and lasted for seven years . Television’s depiction of therapy today is a much more realist one. For example In Treatment is an HBO drama   about a fictionalized psychotherapist 53-year-old Dr. Paul Weston  and his weekly sessions with patients. The program, which stars Gabriel Byrne  as Paul, debuted on January 28, 2008, as a five-night-a-week show and now is beginning it’s third year. The therapist certainly is shown with human flaws but as somebody who has genuinely helped his patients. Another somewhat more sensational type of TV production  is the reality TV show Celebrity Rehab and subsequent spinoffs  with Dr. Drew Pinsky who is an internist and addicition specialist who treats various celebrities on each show . The participants are obviously comfortable revealing their addiction problems and how they are trying to get help. When world famous golfer Tiger Woods had marital problems and sexual issues, he was shown going to some kind of a treatment facility.  Psychiatrists and other mental health professionals  have appeared as characters  on  television medical dramas such as ER as well as in some the popular police and crime dramas. They are   usually shown in a very positive light. The evolution of the depiction of psychiatry and mental illness  in the cinema is a fascinating and important story which  has greatly influenced the public’s attitude on these subjects. Two worthwhile books which discuss this subject are Psychiatry and the Cinema by Krin and Glen Gabbard and Reel Psychiatry by David Robinson.

The wide spread use of computers and the Internet has surely contributed also to the changes in the  attitude towards mental illness and therapy. Information about mental illness and treatment is available within a few clicks as is information about any physical condition. Blogs and web sites are easily found on any subject including those that deal with some aspect of mental health. Organizations which have traditionally tried to address the stigma of mental illness such as the Mental Health America ( MHA)National Alliance On Mental Illness (NAMI), the American Psychiatric Association (APA) and many other reputable groups now have very popular web sites which are seen by millions of people. The social media on the Internet such as Facebook and Twitter are facilitating a freer communication which does brings into  the open  psychological concerns along with everything else. It seems to discourage people from allowing painful secrets to fester in a harmful manner. On this blog I recently wrote about a website called Postsecrets where people anonymously post their secrets in the form of an artistic postcard. When a San Francisco resident told of his or her discouragement about life and plan to jump off the Golden Gate Bridge more than 60,000 people responded in a supportive manner.

I am sure that we still have a long way to go before stigma about mental problems and receiving therapy is eliminated. However there are lots of indications that we are moving in the right direction. Most psychiatrists and other therapists are probably well adjusted enough that they don’t need to see their patients praising them on national TV as Ron Artest chose to do. However when someone wants to issue a public thank you it is great to realize that there is no reason to feel that they can’t do it.

Increase APA Revenue $1.5 Million

There are several possible sources of increasing APA revenue. The dues could be increased an average of $50/year over a five year period which would bring an average increase of revenue of $500,000/year. Profits from the sale of DSM V even with half of it going into reserves would probably add at least another $500,000/year to APA revenue. If the APA Foundation took over part of the public affairs activities of the APA, that would allow for an estimated $200,000 year. APPI, publishing arm of the APA, could use the district branches as a commissioned sales force which could provide another $200,000/year of revenue. Having more videoconference could replace some travel costs and increase revenue about $50,000/year. Finally having the APA “go global” could bring in a large number of international members which could increase revenue an estimated $100,000/year. There ideas have the potential of increasing APA revenue $1.5 million/year which could be used to reinvigorate the Assembly and reestablish the APA Components in a responsible manner

Recently I wrote about budget cuts which the Board of Trustees has made to the APA Assembly and the Components as well as the possible implications of them. While attending the APA meeting this past week in New Orleans I had some informal feedback also expressing concerns about the recent cutbacks in the Assembly and the Components. There seems to be a difference of opinion among psychiatrists whether it is time to restructure the APA  to a “ leaner and meaner” organization where activities and functions by necessity have to be cut back because of reduced income. Whereas others wonder if there are untapped sources of income and believe there are reasons for the APA to continue to grow and expand it’s advocacy for our patients and our profession.

I would like to examine several possible sources of increased revenue for the APA, which could be used to prevent a cut back of the Assembly and the Components, as well allow for consideration of developing new important programs.

Dues Increase

If the membership wishes increased services, they should be willing to consider paying directly for them. The national dues have not been increased for several years. There are different categories of membership, which have different levels annual dues. If the dues are increased an average of $50 / member over a five year periods, this would gradually increase the income starting with $380,000 the first year. At the end of the five year period the APA  income would be increased $1.9 million /year. Of course, there is the possibility that some small percentage of the 38,000 members would drop out because of the dues increase. On the other hand, if new exciting activities were developed as described below, we could increase membership. A conservative estimate would put this at an average of $500,000/year

How to Use Profits From DSM V

The APA has made an arrangement with APPI so for DSM V the APA will own the rights to DSM V when it comes out in 2011. I understand the previous performance of DSM IV cannot reliably predict the profits from DSM V. However, we still can anticipate this book will be used worldwide as will the accompanying texts which will be published. Most mental health professionals, institutions, government agencies, attorneys, etc  will want to own a hard copy of it, even though there is a trend to looking things up on the Internet. I also assume that there will be DVD versions of it which will be sold. On the basis of some discussions I had  with people who know something about these things,  I would predict that the APA can anticipate a profit of $10 million over the next 8-10 year for this product. This would be a conservative estimate. Therefore if half the proceeds were put into the APA  reserves that would allow another $500,000/year available for the APA budget.

APA Foundation Could Take Over Significant Part of Public Affairs

The APA Foundation is suppose to be 100% in sync with the APA and certainly shares the same goals and aspiration for mental health and education of the public, increasing public awareness and raising money to do good projects for mental health. It is only because of some technical, legal issues related to taxes that there are separate Boards of the APA and the Foundation . There are efforts being made to allow these organizations to function more in unison in the future. As I mentioned in a previous blog, I believe, the forced reduction of the Communications Component has seriously taken away many opportunities for public affairs programs. I therefore suggest that the Foundation should appoint staff consultants who are very familiar with the previous APA public affairs program as well as the current ones . They should use the resources of the Foundation  to run national, state and  local public affairs programs as a major initiative. They can run a Public Affairs Institute, advise and assist mental health advocates from various District Branches write letters to the editor, run educational training for psychiatrists  etc. They can liaison with the APA while still keeping their independence, if that is necessary. They can take over some of the spending in public affairs that have been in the APA budget. I would estimate that this could easily result in a savings for the APA of at least $200,000/year without any loss in the quality of public affairs for mental health and American Psychiatry.

APPI Should Use APA District Branches as a Commissioned Sales Force

APPI was originally developed as an arm of the APA, which was expected to serve a completely dedicated to the APA mission. It has become the most successful publisher of psychiatric books in the world. Even after having sold the rights of DSM back to the APA they still should be able to make considerable profits. Although there is still that problem of having separate Boards although appointed by the Medical Director of the APA, they should be interested in doing everything possible to support the APA. Every publisher makes arrangements with sales teams to take their books into a particular setting, make sales and then pays them a commission. I propose that each District Branch should become a commissioned sales representative for APPI. They should include APPI advertisement for APPI books in all their mailing with special discounts as well as promoting books at all meetings and activities. District Branch members should be aware that buying their books through the District Branch would allow their DBs to receive significant commissions. Once it is determined how much money the DBs are receiving, a certain percentage of APA support or revenue sharing from the Assembly budget being given the DBs should be reduced. The net result should be increased funding for the DBs and decreased support from the APA to the DBs. It might turn out that APPI might make less of a profit but they would be serving their overall mission to support the APA. There would be an incentive for the DBs to promote APPI books and products which could include sales to the local mental health community who they know best as well as the public in their area. These activities might even drive up APPI profits.  I estimate the APA could save at least $100,000/ year by this method.

Use of State of the Art Video Communication

I know that the APA has made great strides in introducing some video communications and have encouraged the use of conference calls, webinar and perhaps Skype meetings. I personally believe that face to face in person meetings should not be completely eliminated and that the combination of at least one face to face meeting combined with state of the art video/personal computer conferencing is now feasible.  I would suggest that the APA become very aggressive in advocating such communications for at least some percentage of most committee meeting including, as an example, of at  least one Board of Trustees meeting. The savings in hotel, travel, food can make a considerable savings for the APA. One would almost think that the members should contribute to buying their equipment own since they would save time away from practice. However, I believe that an investment by the APA in providing equipment in the short and long  run would save the APA money. I would suggest that the APA could save at least $50,000/year.

APA Needs to Go Global

I have saved my most ambitious proposal for last. I am convinced from what I see happening in the economy, business and in the various activities of so many people that I know, that our lives are becoming more global in every way. I believe that the APA has to begin to take significant steps to become a global (still American) organization.  We need to look at every aspect of our organization and see how we can become more global.

Starting with membership, we should offer a membership category to international members at a reduced cost  (to cover journals , mailings etc plus enough to make a profit for the APA). This lower rate should be contingent on the international members being a member of their own national psychiatric organization or the World Psychiatric Association.. This way we won’t compete with international organizations but would allow them to encourage membership as global members of the APA. Obviously we will need to provide international members with special benefits such as discounts of APPI books, facilitated access to disaster materials, perhaps some special online or Skype CME courses. As part of our efforts to go global, the newly invigorated Assembly (with some increased funding) should have a certain number of international delegates to the Assembly perhaps one from each country or from each major area of the world for a start. Oh yes, the APA Assembly should be broadcast live online (as well as being archived) so our members in the US and all over the world can see American psychiatry in action. While we are doing this we should set up electronic voting which I unsuccessfully advocated for when I was Speaker of the APA Assembly – the price has come down and we do need to showcase the fantastic democratic methods we use in the Assembly when we broadcast the proceedings around the world. I estimate over the next five years we should be able to add at least 1000 global members – so lets figure in the long run we add at least another $100,000 /year income after added expenses are taken into account.

How It All Adds Up

I realize that I am letting my imagination get a little carried away. I tried to build these ideas on facts and speculation that has good foundation. I may be wrong in some of my calculations or may be a little ahead of my time (or perhaps behind if some of these things are being contemplated already). However I tried to be conservative in my estimates and I came up with almost  $1.5 million dollars/year available for reinvigorating  the Assembly and reestablishing the Components in a responsible manner.  I am also suggesting that there may be innovative approaches to increasing available funding.  I encourage our members and leadership to continue to look for newer and better ways of doing things for our patients and our profession.