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

 END

 Any comments are welcome below

 

 

 

 

 

 

 

 

 

 

 

 

My Introduction to Telepsychiatry

The following is an article which I wrote for the current issue of the Forum. This is a publication of the American Academy of Psychoanalysis and Dynamic Psychiatry of which I am the current President.

images-1President’s Message: My Introduction to Telemedicine/Telepsychiatry

By Michael Blumenfield, M.D.

 

There are many psychiatrists and other therapists who have been involved for at least several years with using   computers and video cameras through the Internet to see patients and teach. From time to time over the years I have attended presentations that described the pros and cons of this activity. I recall some of my skeptical colleagues saying until you can smell the patient, they were not getting involved. I always thought that was extreme but recall another statement bandied around that you have to be able to get a very good look into the patient’s eyes in order for this technique to be useful. Still others likened this approach to therapy on the telephone which some favored in rural areas with circumstances where there were no access to in-person therapists.

My interest in this subject was renewed about 3 years ago when I left New York Medical College. I established a practice in Los Angeles and began to explore some new venues. Dr. Elise Snyder asked me if would like to teach and do other activities with the Chinese American Psychoanalytic Alliance program (CAPAChina.org) that used SKYPE and OooVoo to teach classes, supervise therapists, and treat therapists who were in their training program. By this time I had experience using SKYPE communicating with family members and sharing some travel experience live online from far away countries.

CAPA is an extremely well organized program that continues to grow and offers eager Chinese therapists a chance to receive a high-quality two year training program in psychoanalytic therapy. Within a short time after connecting with them, I could not believe that I was sitting in my office talking and interacting with 10-12 Chinese students in three different cities. Needless to say, I do not speak Chinese and to be accepted into the program the Chinese students must be fluent in English.

I was re- reading and discussing some classical psychoanalytic papers which I hadn’t read in many years. I was also learning about some subtle cross cultural concepts. For example, the concept of shame in China is a very important one and is quite different than the concept of guilt which is so important in western culture. I recall one homework exercise I gave the students which was to discuss clinical examples of shame in their therapy work or alternatively from their own life experience. One bright student told how he as a young boy would make up stories of things he said that he did wrong order to show shame which pleased his grandparents and made them very happy.

The opportunity to do one to one supervision and also some individual psychotherapy also revealed new issues reflecting the Chinese experience. For example, a patient after several months in treatment began to mention that when she was five years old, she and her family had to move to the countryside. Her memories about that time seemed to be very benign. Doing some calculations in my mind about the little Chinese history that I did know, I inquired if that wasn’t a difficult time when many people were being punished and treated badly as part of “re-education “ measures. This inquiry led her to begin to rock and back and forth and cry as she recalled that that was a terrible time in the history of her family.

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       CAPA Graduation Ceremony in Beijing

In other ways the issues of trust, speaking freely and the resistances to doing so are important in therapy but are colored by the Chinese culture and the prevailing changing atmosphere in China. All this was very enlightening to me and emerged from my limited work with CAPA and telepsychiatry. My work with CAPA led to me to going on a CAPA study tour where I was able to lecture in China, meet some the students in person and attend the student graduation program in Beijing.

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Our experience with CAPA led my colleague Dr. Jim Strain and I to set up a non-profit teaching program in Psychosomatic Medicine for third world countries (PSMWW.com). We had decided to do this rather than write a second edition for a large textbook we edited in the above field. We thus far have taught two 8-session courses in South America and in Rwanda via teleconferencing. One of the systems we use allows us to share our computer screen and that makes the projection of PowerPoint sides particularly useful. However the most meaningful part of the teaching is the direct interaction with the students. This exposure, and the nature of the teaching material we have chosen that is greatly influenced by psychodynamic experience, is also proving to be  interesting from a cross cultural point of view.

I had a completely different experience when I signed up to work one half-day a week with the California Telepsychiatry Group (caltelepsych.com/) that is part of American Telepsychiatrists led by Dr. John Schaffer. This group has a contract to provide psychiatric care via video conferencing for several mental health clinics in central California.images-2 They use a system called Web-Ex which seems to be even better than SKYPE and OOVOO. They also have a sophisticated online electronic medical record that I can easily access as well as an online prescribing system called Infoscriber where I can directly prescribe to any pharmacy in California.

American Telepsychiatrists has many other sophisticated features. The sessions take place in a private room in a clinic while I am comfortably in my office in Los Angeles.  I  have a psychiatric nurse present with the patient and/or a translator when needed. While I am doing mainly psychopharmacology, I can refer the patient to individual and group therapy, to primary care physicians, and to substance abuse programs, and I can order lab work, communicate with other health care workers, and send patients directly to the hospital or do anything that I might do from my private office. The psychiatric nurse with whom I work, and the staff, are helpful and supportive. Patients adjust easily to this form of communication and most of them are extremely appreciative of the care that thteleconferenceey are receiving.

Only recently have I considered using telepsychiatry in my private office practice. There were two instances where college students with whom I was working were going back to college and they wanted to continue their sessions while they were away at school. They were very comfortable with SKYPE and one of them used it on his i-phone. The therapy didn’t miss a beat. One session took me zooming from room to room as the student’s roommate had unexpectedly appeared and the patient was trying to keep his therapy confidential.

I started using SKYPE to treat a new patient who was from another city and expected to be traveling to Los Angeles from time to time for occasional face-to-face sessions. Of course resistance and transference issues have to be considered when there is the lack of an in-person presence. Recently a patient being seen through SKYPE asked if I would mind if he lit up a cigarette. That issue hasn’t come up in over 20 years since I removed the ash trays from my office. So while the smoke wouldn’t bother me, of course I had to explore the patient’s state of mind for wanting to light up at that time.

We are becoming more of a global society. AAPDP is having an increasing number of international members. We comfortably travel in airplanes and through the Internet. It seems only logical that we should take our professional lives with us on these journeys.

Dr. Blumenfield Assumes Presidency of the American Academy of Psychoanalysis and Dynamic Psychiatry

Message from Michael Blumenfield, M.D. incoming President of the American Academy of Psychoanalysis and Dynamic Psychiatry.

The American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP) is an organization made up of  psychiatrists who are interested in psychoanalytic and psychodynamic theory and the application of it to various aspects of psychiatry and human behavior. At the conclusion of the annual AAPDP meeting this May in Philadelphia I assumed the two year presidency of this organization. The following is my first official message as President which will be published in the AAPDP Newsletter. If you would like more information about this group please look at our website or you may reach me with the contact information given at the end of this blog.

Message From Michael Blumenfield, MD.

President of the American Academy of Psychoanalysis and Dynamic Psychiatry

 

I am very pleased to begin my two year term as President of AAPDP. Cesar Alfonso has done an outstanding job during his presidency by both expanding the membership and unifying our organization. During this time we have seen an increase in our membership especially among our younger colleagues. The success of the Teichner Scholar Program and the establishment of the Scott Schwartz Award have been two very important highlights of the past two years. We have also seen the successful passing of the torch from one great editor of our journal, Doug Ingram, to another great editor, Richard Friedman, who will be assisted by his outstanding co-editor Jennifer Downey. Just as significant has been the changing of our journal name to Psychodynamic Psychiatry, which will widen our connection with the body of psychiatrists who share our interests in psychoanalytic and psychodynamic theory and therapy. In addition, our Forum magazine under the able editorship of Jerry Perman continues to provide interesting articles about our members and our organization as well as creative pieces on a variety of pertinent subjects.

We all know that there are evolving changes in the delivery of mental health care. Many psychiatrists who value a psychoanalytic and psychodynamic perspective frequently find themselves in settings where they don’t have a chance to discuss these concepts and case formulations with colleagues. While applying these skills in various settings related to psychopharmacology, C/L psychiatry, short term therapy, inpatient hospitals etc , they are often isolated from colleagues who have a psychodynamic background. Even those psychiatrists who do long term therapy need a home to share their interest in their work and that home is the Academy of Psychoanalysis and Dynamic Psychiatry.

Now is the time to surge our membership. I am proposing that over the next two years each member invite at least one new colleague to join AAPDP each year. I believe that we could double our membership in the next two years, which would allow us to expand our programs and activities. Not only should we be inviting our junior colleagues (residents, medical students and early career psychiatrists) to join but we should also offer our seasoned colleagues an opportunity to join AAPDP. I have been pleasantly surprised to see some of my old friends and colleagues quite receptive to being invited to join our organization. I know that many of you will be glad to chat by phone with a perspective new member in order to be the second sponsor needed to join, as Membership Chair Jerry Perman, Past President Cesar Alfonso and I have done this past year. The membership application is easily accessed from our website (AAPDP.org) or from our office.

As we engage in a membership drive, we need to highlight the benefits of membership as well as expanding them. I have already mentioned our publications, which include this Academy Newsletter. Whether or not you were able to attend our recent annual meeting in Philadelphia, I hope you appreciate the outstanding program that was put together by Kim Best and Gene Della Badia. I have asked overall Program Chair Eugenio Rothe to serve a second term and I have appointed Mary Ann Cohen to lead the efforts in putting together the 2013 San Francisco meeting. Already there is a great program committee planning this meeting with the theme, Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychiatry.  We have a mentorship program for our younger members and also have Grand a Rounds Program, which helps identify speakers for programs throughout the country. I have appointed Joanna Chambers as the new Chair of the Education Committee. I am looking forward to our organization exploring the possibility of developing Special Interest Groups that can meet at our annual meeting or online during the year, Peer Supervision Groups, and also exploring how we can interface with long distance learning and the social media. I have appointed President-Elect David Lopez as Chair of the Public Relations Committee and Mims Cohen will continue as Chair of our Web & Electronics Committee.  Our website looks great and we will continue to build on it (AAPDP.org).

Being a medical organization, we have always been very close to the American Psychiatric Association. We have an outstanding Representative to the APA Assembly in the person of Eric Plakun who was a candidate for Assembly Recorder this past May. The Academy is an Allied Organization of the APA and some of our members are on various APA committees. We also continue to interact with our colleagues in other specialty organizations, which many AAPDP members also join and vice versa. We organize and plan various joint panels at their meetings and at our own annual meeting.

The world we know is getting flatter all the time. In the past few years, we have been expanding our international interactions. Joan and Matt Tolchin have established a close relationship with OFIFER (Italian Psychoanalytic Group), Cesar Alfonso led a study tour to Thailand and has been invited back for a second time. Several of our members are teaching in the CAPA program (Chinese American Psychoanalytic Alliance) via telepsychiatry on the Internet. There have been yearly CAPA tours to China on which several of us have participated in lecturing and sightseeing. Dr. Elise Snyder, the remarkable founder and leader of CAPA continues to recruit teachers and supervisors from AAPDP for CAPA. We also anticipate expanding our connection with the World Psychiatric Association (WPA). Last year our Executive Council accepted the recommendation of our International Task Force and lowered the dues for international members making it more feasible for our international colleagues to join AAPDP. We hope to develop further connections with our international colleagues, which can include hospitality arrangements, joint panels and presentations at various international meetings. I have appointed Sylvia Olarte as Chair of our new International Task Force.

I will be communicating with all of you on a regular basis about new developments in AAPDP. Please be sure that we have your correct email address. I also need and want your ideas for AAPDP. Please write or call me anytime.

 

Best regards.

Michael Blumenfield, M.D.

President- American Academy of Psychoanalysis and Dynamic Psychiatry

Tel: 818 564-4207

Email: mblumenfield@aol.com

Telepsychiatry Today and Tomorrow

Three examples are discussed where he author has become involved in the delivery of psychiatric treatment via telepsychiatry (video conferencing). The first is in a county rural mental health clinic in California. The second is in conjunction with the Chinese American Psychoanalytic Alliance (CAPA) where mental health professionals in China who are in a training program provided by American teachers via SKYPE ( video conferencing) desire to have their own personal one to one psychotherapy by this technique. The third is psychotherapy in the United States for private patients who for a variety of reasons find it more convenient and feasible to have their therapy via telepsychiatry.

A county rural mental health clinic in California is set up to provide  psychiatric  services to the surrounding area but there aren’t enough psychiatrists in the area who are able to travel to staff this clinic morning and afternoons five days per week.

An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.

CAPA Plans 3rd Study Tour

The Chinese American Psychoanalytic Alliance (CAPA ) will hold it’s 3rd annual tour to China starting on October 22. CAPA provides training program for Chinese mental health professionals in psychoanalytic and psychodynamic psychotherapy. with classes and supervision which utilize video conferencing on the Internet. The tour will be led by the Founder and Director of CAP Dr. Elise Snyder and will include visits to various mental health facilities where some of the travelers will give lectures. . Dr. Blumenfield reviews his experience on the second annual tour held last October.

CAPA is the Chinese American Psychoanalytic Alliance which is an organization founded and directed by Dr. Elise Snyder.  It provides a training program for Chinese mental health professionals in psychoanalytic and psychodynamic therapy via classes, supervision  and their own analysis with video conferencing on the Internet. . Last October I participated in the CAPA 2nd annual study tour to China and there will be another such tour this coming October. The following is an article which I wrote for the June issue  the Forum, the magazine of the American Academy of Psychoanalysis and Academic Psychiatry. The tour was led by Dr. Snyder who was accompanied by her husband Dr. Michael Holoquist a Professor Emeritus at Yale, who like his wife has traveled extensively in China. There were 27 people on the tour and all were psychoanalytically oriented mental health professionals and their spouses. Most, but not all, were participating in the CAPA teaching program. The guide for the tour was Simon Chen, an executive in the Chinese travel company, which organized the tour and who told me that he chooses to only accompany VIP tours. He was an excellent guide and stayed with us the entire trip. He not only told us in detail about all the places we visited and the history of China  but was able to answer our probing questions about contemporary life in China. In each city which we visited, we were also joined by a local guide especially chosen  by Simon who provided additional knowledge and insight about the things of interest in their locality.

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CAPA 2010 Tour: Top: S. Chen, L. Brown, F. Gittless, B. Thurer, C. Kahn, A. Entin, C. Brown, T. Cromie, C. Weyand, C. Bassen, B. Stockton, S. Frame, I. Stockton, E. Snyder, R. Mair, S. Browne, M. Rogolin, E. Rigolin, M. Blumenfield, M. Holquist; Bottom: E. Ronis, E. Gittless, M. Broder, S. Thurer, S. Blumenfield, J. Duncan, N. Logan

There was no better place to start than the city of Beijing, which is the Capitol of China. It has a population of over 22 million people and there are tall skyscrapers, crowded streets, upscale stores, a night food market and a lot more. Yet nestled in the center of the city is the Huotong section, which is made up of a series of courtyards with houses dating back 100 years. The streets here are quite small and to explore it we needed to take a pedicab which is a small open  carriage pulled by a man riding a bicycle. This was one of the occasions that we were not going around with the entire group but our guide did arrange for us to to have lunch with  a middle aged couple living here . After showing us around their small home they told us about their son who now teaches martial arts in San Antonio, Texas.


During our stay in Beijing we also visited the Forbidden City, which is 500 years old and was built by the Ming Emperor Yongle. It has 8,706 rooms. Nearby is Tiananmen Square, which is the site of political drama in China from the 1960s cultural revolution to student demonstrations in 1989. Some CAPA members made presentations at Beijing University. Whenever we gave a talk we always had a translator, although many of the young people do speak English. We always had a chance to chat individually with students who would come up to us before and after the formal presentations. Then there was a very momentous moment as  Dr. Snyder conducted the graduation of the first CAPA class. This was a very important event for the students and it was very special for Dr. Snyder who had worked so hard to bring this about.


It was very striking how we could be dealing with something in the modern age one day and then the following morning do something such as climb and descend part of the Great Wall of China. On another day, in the morning, we visited the Ming Tombs, which were built 600 years ago and then in the evening we went to the theater and saw the very dramatic and powerful Kung Fu show. Afterwards, we had the opportunity to chat with the participants of the show. We also saw people exercising and playing Chinese musical instruments on the grounds of the Temple of Heaven.  We paid a visit to the the site of the 2008 Olympics which had been held in Beijing. There even was a very artsy area called the 799 Art Zone which reminded us of Greenwich Village in New York except there were large statutes on many of the streets.

Our next stop was Xi’an, a few hours southwest by airplane. It’s history dates back to 100 BC and it has a mere population of 7.5 million people. It was here that I made my first presentation at  Shan’xi Provincial Hospital. I recall one of the questions asked of me after I spoke had to do with whether older therapists could treat younger patients (obviously asked by a younger person). Probably the most dramatic sight in this city were the Terracotta Warriors which were statues of many soldiers buried with the first emperor “to protect him” (he originally wanted the actual live soldiers buried with him but was persuaded against it).  We bought a souvenir  of one these statues which resides now with us in our home in California.  We covered a few more museums and the very fascinating evening Moslem market.

Still further southwest was our next stop in Chengdu. The city is more than 2000 years old and has a population of  10.2 million people. It is the capitol of Sichuan  and is known for its cuisine. A person from our group gave a talk on Trauma, Enactment and Integration. For some members of our trip the visit to the Panda Home was the highlight. You get a chance to even hold a baby cub and to watch these cute bears frolic around in the grass. One evening we made a visit to the Chengdu opera, which is not like any opera that you have ever seen, but certainly held our interest. On another day we came across an interesting Chinese custom in the People‘s Park. It seems they have a tradition of people dancing with strangers. So our entire group waltzed around the outdoor dance floor with people we had just met.


We then headed east to the coast and probably the most dramatic city of our trip and that was Shanghai. Once a muddy fishing village, its greater metropolitan area now has more than 16 million people. Since the late 1990’s there has been a great construction boom and this city now is China’s economic spearhead. The skyline matches any that we have seen throughout the world and the view from their highest tower is magnificent. In the suburbs we visited Suzhou which has been named the Venice of the East.  We saw how silk paintings are made, visited the Jade Buddha and then ended up in the Eastern China Normal University where several members of our group gave talks. There also was a second graduation for students in this part of the country. We then went to Shanghai Mental Health Center where I and several other CAPA members also gave some lectures and interacted with faculty and students..

On our last evening in Shanghai we had a celebratory dinner where  our guide also presented us with a special cake. Some of the group departed for the states on the following day, while my wife and I with several others went on to the famous ancient city of Kaifeng. It had been the capitol in the Song Dynasty and is the place where a Jewish synagogue was built during the first century. We visited with descendents of those Jews who told us the history of the Jews in China and their desire to rebuild a synagogue there in modern times. As in every city where we traveled there were fascinating museums, Pagodas, Buddhist Temples and beautiful gardens. I even had an interesting “incident” when we took a trip on a hovercraft on the muddy Yellow River. We walked around on a small island and I sank up to my knees in mud and had to be pulled out.

It was not only the beautiful sights, introduction to the history and Chinese culture  that was so worthwhile on this trip, but it was some of the insights that we developed in chatting with our guides as well as the students, faculty and other people we met. This included of course, the discussion between our fellow travelers who were colleagues from all over the United States. I came to understand how the Cultural Revolution, which occurred in the 1960s eliminated many of the doctors and intellectuals who might be the Chinese teachers of psychoanalytic theory today. It also became clear how the Chinese are very proud of the economic growth which they have sustained in the past 20 years with the help of free enterprise and capitalism throughout the country but yet under the clear authoritarian rule of the non democratic Chinese government. They still have a long way to raise the standard of living of the average person especially of those who live in rural areas but there seems to be a confidence that they are well on this road. They seem to have a willingness to tolerate the absence of freedom, which we in the United States take for granted but yet value a great deal. It was very enjoyable to chat with our colleagues on the bus rides or during meals while some of us still struggled with chopsticks. We were able to exchange ideas about teaching experiences with CAPA and review such issues as the meaning of China’s one child policy in the psychological make up the Chinese or about the difference between shame and depression.

Over all this was a very gratifying and stimulating three weeks. I urge you to consider participating in the CAPA program but whether you do or do not do so you should think about taking the next CAPA trip to China. You can get more information about CAPA and the next tour which will begin on October 22nd by going to http://www.capachina.org/CAPA/Events.html. You can also view a movie that I put together about our CAPA tour by going to http://gallery.me.com/ronellan#100246.