Immediate Past President Bernstein, President-Elect Jeste, Speaker Sullivan, members of the board and the assembly, past presidents, and distinguished guests: it is my privilege to welcome you to the 165th Annual Meeting of the American Psychiatric Association.
I am especially pleased that our meeting this year takes place in Philadelphia, the birthplace of Benjamin Rush, who is often referred to as the “father of modern psychiatry.”
Rush was one of the five physician signers of the declaration of independence, and he was a pioneering thinker in our field.
To quote Walter Barton from his volume on the history of the APA, “Rush believed that mental illness was a disorder of the total person, with an origin in bodily impairment and in emotionally stressful events.” Today, we might use words like “the stress/ vulnerability model of disease,” or “bi-directional gene/ environment interaction,” to describe the same basic concept, now supported by solid research findings. Yet these early words of Rush seem fresh and cogent today, right on target with the theme of this meeting, which I’ll expand to call “patient-centered, integrated care.”
You remember the four principles I listed last year as particularly important priorities for the APA:
- Psychiatry is part of the house of medicine,
- Our patients have a right to quality treatment,
- Fragmented care is not quality care, and
- Research and education provide the best blueprint for our future.
Rather than comment on each of these one by one, as I did last year, I’d like to consider them together, as critical elements of our goal to achieve high quality, evidence-based, patient-centered integrated care, as we strive to be as effective as we can in a complex time of health care reform.
One of my favorite off Broadway productions from many, many years ago was a little musical called “In Circles,” which put words of Gertrude Stein to music. Stein said, “A circle is a necessity. Otherwise you would see no one.” I like that quote. It reminds us to remember where we’ve been, and to wonder if our brand new ideas may not be so new after all. So I decided to circle back and take a look at our last decade.
The APA met in Philadelphia 10 years ago, in 2002, and Richard Harding, M.D. was our President. In his presidential address, he said, “where will we get the will to create integrated public/ private health care systems that will equitably and professionally deliver care to with mental illness, including substance use disorders?” He went on to say that the task will be “incremental,” that we “must be in it for the long haul,” and that we have “an unmatched scientific knowledge base that will lead us to new treatment resources and health care delivery systems.” In response to his address, President-Elect Paul Appelbaum, M.D. described the systematic defunding of psychiatric care as “a crisis at our doorstep.” Among many areas of concern, Dr. Appelbaum stated that “the federal government decided that the goal of a balanced budget could be reached only by cutting back Medicare payments, especially to teaching hospitals.”
We all remember the cascade of events following the balanced budget act and its impact on teaching hospitals. But this sounds awfully familiar today, as we monitor the federal budget deficit reduction process, with graduate medical education perilously in the cross-hairs, and with budgets everywhere dealing only with cuts. Here’s one example; I recently obtained data from the National Association of State Mental Health program directors showing that from just 2009 to the present, the total reduction in funding to state mental health administrations nationwide is estimated to be 3.4 billion dollars. Not to mention the seemingly insoluble sustainable growth rate problem that would cost hundreds of billions of dollars to fix. So remembering Dr. Appelbaum’s 2002 metaphor, I believe the crisis is no longer at our doorstep but is through the door and in the room with us.
I’d like to change the subject from the crises of today, but let’s keep looking back for a bit longer. When Dr. Applebaum became President, he appointed a task force chaired by Steve Sharfstein, M.D. to develop “a vision for the mental health system.” The task force report was presented to the Board of Trustees in March, 2003. The following year, President Marcia Goin M.D. appointed a work group to actuate the vision statement, chaired by Dr. Appelbaum, which presented its report to the Board of Trustees in March, 2004. Both of these documents are thoughtful and comprehensive, and they remain remarkably relevant today.
Dr. Sharfstein’s report stated that mental health care should be fully integrated with the treatment of substance abuse disorders, primary care and other general medical services. In turn, Dr. Appelbaum’s report stated that most Americans have a primary care physician who should be their point of entry to needed mental health treatment. Many persons with mental disorders can be given a diagnosis and be treated in the primary care system, especially if psychiatric consultation and referral of the more difficult cases is readily available.
It is interesting, in the spirit of circling back, to re-visit these aspects of our APA vision and to evaluate how we have done. In my judgment we’ve done pretty well, though better in some areas than in others. Sometimes very good ideas, such as integrated care, are ahead of their time, or they are impeded by fiscal and political circumstances, and we need to be in it for the long haul.
A position statement entitled “Principles for Health Care Reform for Psychiatry” was approved by the APA Board of Trustees in 2008. It derived from the earlier Drs. Sharfstein and Appelbaum reports, and it emphasized that psychiatry should be integrated with medicine in primary care settings and hospitals. APA followed this position statement with a report on the integration of psychiatry and primary care in 2009, which stressed that integrated care, is more than the simple co-location of two distinct services but requires interdisciplinary communication, collaboration, and coordination of service delivery. Furthermore, we now have growing evidence of the benefit and cost-effectiveness of integrated, or what is sometimes called collaborative, care. I’ll mention one example: in the New England Journal of Medicine in 2010, Dr. Katon and colleagues reported on a study of patients with co-occurring depression, poorly-controlled diabetes, and coronary heart disease. The collaborative intervention group outperformed the controls on all measures at 12 months, including cholesterol levels, systolic blood pressure, depression scores, quality of life, and satisfaction with care. As new models of health care such as medical homes and accountable care organizations come online, psychiatry needs to be at the table.
This year, I appointed a new Board of Trustees work group on the role of psychiatry in health care reform chaired by Paul Summergrad, M.D. Paul presented the work group’s agenda and timetable to the board at its meeting in March, 2012. The work group emphasized that health care reform is being driven by market forces, whether or not the affordable care act remains intact (and we await the judgment of the Supreme Court on that question). I believe there is growing recognition and receptivity within medicine at large of the critical importance of our partnership with medicine and primary care. Our participation in the American Medical Association has never been stronger, with many of our members in key positions of leadership, in particular Jeremy Lazarus, M.D. as the current President-Elect of the AMA.
Other groups in organized medicine also understand the central importance of psychiatry, as new models of care evolve. Let me read you a quote from a recent document on the patient-centered medical home being developed jointly by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association: science has rendered untenable the implausible and artificial division of people into parts, particularly mental and physical parts.
Given that over half of primary care patients have a mental or behavioral diagnosis or symptoms that are significantly disabling, given that every medical problem has a psychosocial dimension, and given that most personal care plans require substantial health behavior change, a patient-centered medical home would be incomplete without behavioral healthcare expertise and treatment support fully incorporated into its fabric. A whole person orientation simply cannot be imagined without including the behavioral together with the physical.
Meanwhile, significant achievements have been made in the last 10 years in many areas of our vision for mental health. Though stigma continues to be a huge problem for our patients and our field, I believe we are making progress. The mainstream medical nature of depression, for example, is becoming well-known, and I think depression is coming “out of the closet,” just as cancer did years ago. The same is true for some anxiety disorders, such as PTSD, and for alcohol use disorders. Other conditions will take more time, but we’ll get there. The technology of neuroscience research is expanding rapidly, extending the promise of new treatments and of improved capacity to match the right treatment to the individual patient.
And, of course, we celebrate the Wellstone-Domenici Mental Health Parity Act of 2008, a landmark culmination of a long- and hard-fought battle by a cast of thousands. But even as we adjust to the new law, we learn of companies that are looking for loopholes. Our Department of Government Relations, Office of Health Care Systems and Finance, and our new in-house counsel are aggressively monitoring for such situations and are actively intervening when they find them, in collaboration with our state associations and district branches. The same is true on other fronts, such as scope of practice. These and other challenges need our well-orchestrated and sustained attention.
The workforce issue remains a huge concern, illustrated by this year’s drop in the percentage of graduating medical students choosing psychiatry as a specialty. I’m told that medical students these days say that “the road to happiness” is to choose any one of four specialties: anesthesiology, dermatology, ophthalmology, or radiology. You are guaranteed plenty of business, a good income, controllable hours, and minimal night call. But students who do choose to go into psychiatry say they want to have time to spend with patients, to understand what goes wrong (and why) when thoughts, feelings, and self-control get out of balance. And most of all, they want to connect with their future patients in human relationships of healing.
I, for one, believe that the fundamentals of the therapeutic relationship define our profession at its best and are the heart and soul of patient-centered psychiatric medicine. This is the real road to happiness. I would like to elaborate a bit on this last point, as I bring these remarks to a close.
We all have formative moments early in our careers, and one of mine was the opportunity, when I was a resident, to hear Donald W. Winnicott present a talk at the New York Psychoanalytic Society, entitled “The Use of an Object.” Though his terminology seems antiquated now (“object” referred to the analyst), the relevance and vitality of his message has stayed with me. In essence, he argued that for patients to benefit from treatment, they must accept the therapist’s independent existence. Winnicott said, “It is the patient and only the patient who has the answers” and that “[w]e all hope our patients will finish with us, and that they will find living itself to be the therapy that makes sense.” A recovery model, if I ever heard one! Of course not all patients will “finish with us,” and a recovery model includes appropriate continuing care, just as we continue to see our cardiologists, endocrinologists, and ophthalmologists. But others can and should finish with us.
Let me mention two examples from my own experience, one of a patient who needed continued treatment and support, and one of a patient who needed to finish and did so. The first patient, let’s call her Elaine, saw me in the community psychiatry clinic once a month and was maintained on antipsychotic medication. Between appointments, she would telephone me frequently, and I always took her calls. I would answer the phone and there would be silence. I’d say, “Elaine, is that you,” and she would hesitantly answer, “oh…I just wanted to know if you were there.” She was then fine until either her next appointment or her next phone call. Her sense of “object constancy” was shaky, and I wondered how things would go for her down the road. After I moved away, I saw her by chance many years later on a return visit to New York. She recognized me right away and came over to say hello with a big smile. She was still being followed in the community clinic and was still on medication, but she had done pretty well, and she proudly introduced me to her husband.
The second patient, Dr. B, was a severely obsessional young man whom I saw three times a week for several years. He had a doctorate but had not been given tenure at a well-known university, due to his work paralysis. He felt ashamed that he had failed in academia and had had to resort to a job in industry. He was bewildered about why his wife had left him, though he said she told him it was because she could never get any real feelings out of him. He was an unhappy man.
After some time in treatment, I thought I understood how his wife must have felt. Dr. B was always punctual, courteous and cooperative, eagerly trying to please me. But the sessions were amazingly sanitized, colorless, and cerebral. At one point, I interrupted him and said something like “you know, I wonder if you have any idea how hard you are on me?” He was thunderstruck; “what do you mean,” he said. “I do everything I can to please you. I work hard to think about everything you say or suggest. I don’t know what else I could do.” Sounding, I’m sure, a bit like his ex-wife, I said, “That’s just it! You don’t let me exist. You don’t let me be a real person in the room with you. You never disagree with me, you never get angry,” etc., etc. – you get the picture. And, yes, we could have an interesting discussion about what we might call my “deviation from technical neutrality.”
For a while, Dr. B thought I might as well have been speaking a foreign language. However, as time went on, it became clear that my impulsive intervention had stimulated a turning point in treatment. He gradually revealed that after his mother had died when he was 4, he felt desolate and isolated, never able to connect with his distant father or, later, his disapproving, perfectionistic step-mother. He had kept secret memorabilia of his real mother in the attic, where he would go to soothe himself.
It became clear that for him to emotionally connect with a present-day human being, he would have to let his real mother really die. Eventually, he did so. After a while, he re-married, and he achieved for the third time a warm, mutual relationship. The first time was with his real mother, but that was when he was a young boy. The second time was with me. He gave me a big bear hug on termination, later sending me photos of his kids. Thinking back on his case now makes me circle back to Winnicott’s talk in New York. I remember that he finished his talk with a case example, describing the end of the analysis this way: “for my patient, an object now existed in the world, and his world could begin.”
What am I getting at? Here’s the point I’m trying to make. As we wrestle with changes in health care, battle to sustain parity for our patients, fight to improve reimbursement rates, educate about the effectiveness of psychiatric treatment (and here I mean comprehensive medical psychotherapy and pharmacotherapy), work tirelessly to combat stigma, and pursue all of the values so carefully articulated a decade ago in the APA’s vision for the mental health system, and as we embrace integrated care in partnership with the rest of medicine, we need to remember, as with my patient Elaine, to be there for our patients. Actually, it takes more than remembering – we need to insist on the essential healing nature of the therapeutic relationship.
I’m indebted to Walt Menninger for bringing my attention recently to an article in Fortune Magazine in April 1935, which was a special feature on well-known “sanitariums” at the time. Fortune referred to three basic principles involved in “the Menninger therapy”:
- The synthesis of the medical and psychological approach,
- The individualization of treatment, and
- What “Freudians” would have called “transference” but what Dr. Karl Menninger called “scientifically controlled friendship.”
That’s a term I hadn’t come across before, but it gets right at what I’m talking about.
Over 100 years earlier, in a letter dated September 24, 1810 to the managers of the Pennsylvania Hospital, Benjamin Rush stated, in the language of his day: “there is a great pleasure in combatting with success a violent bodily disease, but what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!”
So in closing, I call upon all of us to stay the course and to protect the heartbeat of our field – our healing partnerships with our patients, which can and must define how we collaborate with our colleagues as we develop new models of integrated care. It has been a privilege to serve as your President this year. I have worked closely with Dilip Jeste, M.D. and I am confident that we will be in good hands under his leadership.
I could not have served you well this year without the help of the board, the assembly, the APA staff, my great and supportive colleagues at the Menninger Clinic and the Baylor Department of Psychiatry, and especially my wife, Dr. Karen Oldham, who has been very patient with her absentee husband!
Finally, I would like to acknowledge the help of all of the members of the APA. You have all “been there” for me, as I hope I have been, for you.
Thank you very much.
– John M. Oldham, M.D.
