Dr. Snyder: I think this is one of the longest interviews on record. We began in May of 1986, 20 months ago. At that time you had been awake all the previous night working on the lawsuit. You said then that you didn't know about being President. Now you do. How has it been?
Dr. Simons: I'm feeling good, both because the end is near and also because of what we've accomplished.
Dr. ES: Let's start at the beginning. Tell me about yourself, where you're from and so on.
Dr. RS: I went to medical school at Northwestern, did my psychiatric residency at the Menninger Clinic, and then spent my Army years in Boston. I did my analytic training at what was then Downstate, now NYU. For the past 12 years my family and I have been in Denver. I'm Professor of Psychiatry at the University of Colorado School of Medicine. Both my wife and I were from the Midwest, not native New Yorkers, so we knew something did exist west of the Hudson. We've been very happy in Colorado. My main job is to coordinate the Human Behavior Course for the second-year medical students. It's a long, 99-hour course, a major commitment by the Department to the education of 130 future physicians.
Dr. ES: And you use your textbook.
Dr. RS: Yes, but we also use 35 different lecturers. Students have a range of models with different perspectives on human behavior. The class is divided into 20 small groups and each group has two or three teachers.
Dr. ES: It sounds like a wonderful course. You're also a training and supervising analyst at your institute?
In January 1988, Elise Snyder interviewed both Richard C. Simons whose term of office as President of the American was ending and Homer C. Curtis whose term of office was about to begin.
Dr. RS: Yes. Denver is one of the four institutes of the American that is part of a department of psychiatry. My work at the institute is my other big commitment.
Dr. ES: What positions did you hold in the American before becoming President?
Dr. RS: I was Chairman of the Committee on Associate and Affiliate Membership for four years. I was pleased to have that opportunity. It is so important for the future to foster identification with the Association and to have the input and enthusiasm of the candidates.
Dr. ES: Your very deep commitment to the education and training of the young has been apparent throughout your professional career. What else have you done in the American?
Dr. RS: I was Secretary for two years, then President-elect and now President. My first task, as President, was to deal with the lawsuit in a responsible manner. I think we have done that. I'm especially grateful to the Executive Committee, and to Helen Fischer, for the support they've given me and the Association. We now have a superb attorney, Joel Klein, who understands the Association. Jay Katz' advice and wisdom have also been available to us throughout this time. The Executive Council has functioned wonderfully as the Board of Trustees of the organization. One of my most important responsibilities has been to keep both the Executive Council and the whole membership informed. In the one financial assessment that we had to make, approximately 95 percent of the membership contributed. So I feel very good about the cohesiveness of our members. While I can't predict the future, I do feel hopeful about the lawsuit.
Dr. ES: When you ran for Presidentelect, had the lawsuit already been filed?
Dr. RS: No, the election took place in the fall of 1983, and the suit was filed in March of 1985.
Dr. ES: Have you had contact with the plaintiffs?
Dr. RS: I became President-elect in May of 1984. That meeting in San Diego had concluded without a decision on the Spruiell Committee's report regarding training of non-medical people. They had presented three different models for consideration. There was no consensus on any one of the models. We didn't know how to proceed because we did not have a consensus on one of the models. Since we could not proceed, we had to wait. That need to wait seems to have been experienced by some of the non-medical community, especially by Division 39, as our having given up on the issue. We were not giving up, we were just waiting until we could find a model on which we had a consensus. We first heard rumors that there might be a lawsuit that summer. Ed Joseph, Homer Curtis and I went to Washington and met with several of the key people in Division 39 to ask them what had happened.
Dr. ES: Was that your only personal contact with the plaintiff?
Dr. RS: After I became President, there were several meetings.
Dr. ES: So these contacts were not handled by lawyers for the two sides; you were also present at those meetings. I have wondered just how much your Presidency had been a hands-on affair, particularly with regard to the lawsuit. You must have had some very different notions of what you would be doing during your Presidency when you ran for office. Twenty months ago, I was going to ask what your hopes were for your Presidency. But now I'm going to ask you what you have accomplished.
Dr. RS: I was hoping to make a contribution to the evolution of the Association, helping it to be responsive to younger members, to new developments in the sciences, to outcome studies in psychotherapy and psychoanalysis. In other words, I wanted to help the American make the changes necessary for it to remain viable and creative, a leader in the world of psychoanalysis.
Dr. ES: I know the lawsuit has taken huge amounts of time. What have you been able to do in the areas you mentioned?
Dr. RS: Well, let's talk first about some of the evolutionary changes. I think the most significant was the passage of the Gaskill Proposal in March of ′86. Shelley Orgel, the Chairman of the Board, appointed outstanding people to the Davis Committee and they have implemented the proposal in a very thoughtful and expeditious manner. All 24 applications were reviewed last May and all 17 applications were reviewed this past December.
Dr. ES: I've heard it said that the Davis Committee was running scared.
Dr. RS: I don't think so. The people on that committee, Carl Davis especially, don't run scared. I think they sensed that they had an obligation to assess this initial group of applicants very carefully. People had been worrying about a flood of applicants with very spotty backgrounds and qualifications. Forty-one applications in six months is hardly a flood. Some of them had been waiting to apply for many years. They were outstanding people. I think as we head into the future, the medical psychoanalytic candidates will have the task of getting the training in psychodynamics and in the humanities that used to be part of many psychiatric residencies. The non-medical candidates are going to have the task of getting the life-and-death health care responsibility for patients that physicians get during medical school. Major changes are occurring in psychiatric residencies. At the same time the training in clinical psychology and psychiatric social work has greatly improved. In any case, you really have to assess the individual, what has been his or her education, talent, life experience, and motivation.
I'd like to tell you about some of our other accomplishments. I think all of the committees of the Executive Council have functioned at a very high level during an extraordinarily difficult period in the history of the Association. Let me pick out a few to highlight what we've been doing. I appointed Jerry Mechanick chairman of a new Committee on Professional Insurance. The members represent all the geographical
areas of the United States. The problem of malpractice insurance for individuals and for Institutes and Societies has reached crisis proportions. We decided that this committee would be proactive. We finally have taken the initiative and are now talking with insurance companies around the country. The Committee on Public Information, chaired by Steve Sonnenberg, is also taking the initiative. It's an area in which our Association has been, traditionally and understandably, hesitant about becoming too involved. I think there is now a recognition that if we don't believe in analysis, if we don't present ourselves in a positive way, if we don't have pride in our work and stand up and say so, if we don't explain to the public what analysis is, and what it can do, then no one is going to do it.
Dr. ES: I spoke with some of the candidates at my institute, about how to discuss analysis with patients. I told them that when I do a consultation, I say to the patient, “I think what you need is an analysis.” One candidate said, “I thought we were supposed to be neutral.” And I said, “But not about analysis.”
Dr. RS: And not about anything else that one believes. How can you be neutral about matters of such importance? So, yes, I think you said it very well. The Committee on Public Information is not neutral about analysis. They are making efforts to inform the public, psychiatric colleagues, our colleagues in medicine, about the value of analysis. They have been involved in the mental health awareness campaign of the American Psychiatric Association. Analysts in communities around the country have been designated to participate in panels and networks with other physicians.
A third committee, Government Relations and Third Party Insurance, chaired by John McGrath, deals with the issue of reimbursement. They have recommended the establishment of a Task Force on the Efficacy of Psychoanalytic Treatment, prompted by the work of Drew Clemens, that will gather together what we know from outcome studies in a form that can be readily understood by colleagues in other disciplines, by insurance companies, and by people passing legislation in the government. The complexities of outcome research on long-term psychotherapy and psychoanalysis are much greater than in other psychiatric treatments which are more focused. Our methodology may finally be reaching the point where we can really address these issues. I'm thinking specifically of Lester Luborsky's 1984 book and Bob Wallerstein's 1986 book Luborsky has another book in press which is going to sum up the work of his group and others on outcome studies. At a recent Panel of the American on “the Evaluation of Outcome in Psychoanalysis”, there were presentations by Joseph Schachter from Pittsburgh, Lester Luborsky from Philadelphia, Nathan Schlessinger from Chicago, Gary Martin from Denver, and Bob Wallerstein from San Francisco.
Dr. ES: Do you find the revised DSM-III useful?
Dr. RS: Well, it's a start. There are some things in the Appendix that would not have been there if analysis had not gotten into that struggle. I believe we are going to have even more input into DSM-IV.
Dr. ES: When is that due? Do you know?
Dr. RS: I think the planning has already begun in terms of the establishment of committees. I think analysts are going to be invited to participate on those committees.
Dr. ES: Were analysts invited in the past?
Dr. RS: I think we could have had much more participation in DSM-III if we had been more alert to the importance of nosology and to the importance of making full and complete diagnoses before making treatment recommendations. Had we been more attentive to these issues, I believe we would have had more input into DSM-III.
Dr. ES: So you really think that some of the problems have been ours—our ignoring nosology and not volunteering? You don't believe we were pushed out?
Dr. RS: I think that we have to accept some of the responsibility for not being involved to the degree that we should have been. I think we are trying to correct that.
Dr. ES: Are we meeting any opposition in the APA?
Dr. RS: There are diverse views in the APA about how dynamic psychiatry and analysis are going to be represented.
Dr. ES: Are we having trouble getting representation?
Dr. RS: No. We are asked and our participation is welcomed. When we expressed our interest in what was happening with the APA task force report on the treatment of psychiatric disorders, Bryam Karasu immediately responded with an invitation to us for our input into that process. Homer Curtis coordinated that effort, and all of the chapters in that task force report were read by members of our Association. That all took effort on our part. We had to contact Dr. Karasu and say that we were interested. But once we said that, he immediately responded.
Dr. ES: And Bob Spitzer is equally receptive?
Dr. RS: He was for DSM-III-R. When we expressed a willingness to become involved, he invited our participation in that process.
There was also a conference in Washington this past December, put together by John Talbott and Carol Nadelson on the Future of Psychiatry. A large number of analysts were invited to participate. The American Psychoanalytic Association was one of the sponsors of that conference, so we had official representatives of the Association there as well as many analysts who attended as individuals. So it is up to us to indicate that we want to be involved in these processes.
Dr. RS: I think my wife and children made the greatest sacrifices. I've continued to do my work and see my analytic patients. Many of the issues that arose in the Association couldn't be
dealt with in a five-minute phone call between patients. So my evenings were generally spent on the phone and my weekends in traveling. If someone calls, I always try to get back to them right away.
Dr. ES: You are a good doctor. Would you do it again?
Dr. RS: I hope I've been able to make a contribution at a critical time in the life of the Association. It fell to me to do it and I did ask for the job. Nobody forced me to run.
Dr. ES: But you didn't know what it would be like.
Dr. RS: I had no inkling.
Dr. ES: You would not do it again.
Dr. RS: Let's just say that both my ambition and my vanity have been tempered considerably.
Dr. ES: What about you now? You are going to be in the position of Elder Statesman.
Dr. RS: Sounds very old.
Dr. ES: It has nothing to do with age. Just wisdom.
Dr. RS: As the immediate past-President I'll be on the Executive Council for a period of time.
Dr. ES: I know you want to go home and tend your garden and reestablish relations with your wife and children, but where, in the American, do you want to devote your knowledge, experience, and whatever energy you have left?
Dr. RS: Difficult question. Because I really feel I have given the Association all I could these past two years. There have been tough decisions. A tough decision to change attorneys, a tough decision about the modification of our status within the IPA, and many, many other difficult decisions that had to be, and were, made. I have given it everything that I had and now I want to go home. I also have a lot of admiration and respect for Homer Curtis. He has integrity, he is a gentleman, and he is strong. You have to see him out there climbing mountains.
They call him the Mountain Goat. He is ahead of everybody else. He is going to be a very fine President. And he is going to receive a great deal of help and support from Mike Allison, from Bernie Pacella, and from Austin Silber.
Dr. ES: You must have heard very, very strong rumors.
Dr. RS: We did, and we wanted to find out about them. We went there in good faith, heard their concerns, and arranged for a meeting to be held one month later in New York, at the same time that our Executive Committee was going to be meeting. The Board of Trustees of Division 39 was meeting that same weekend. Four days after the Washington meeting, we received a letter signed by Bryant Welch, Ph.D., J.D., cancelling the meeting in New York. That was the first time we learned of the J.D..
Dr. ES: You refer to the maturing effects of the life-and-death aspect of health care backgrounds. I think that having children can also be a maturing experience. Nowadays, with people putting off the age of having children, questions arise about the maturity of young applicants, particularly those from nonmedical fields. I understand that most of those accepted by the Davis Committee were not what we would call very young people.
Dr. RS: That's right, but it is a paradox, because on the one hand you want the enthusiasm of youth; since analytic training takes such a long time, if it's possible to get someone at an early stage of their career and their life, that's good. On the other hand, I think, your heart has to break a few times and you have to fall on your face a lot of times and maybe make a fool of yourself a lot of times before you really begin to appreciate the struggles of other people. Then you can approach analysis and psychotherapy with humility and empathy. There are some things you can only get through living.
Dr. ES: It is obvious that you are a very young man. Your memory is totally intact.
Dr. RS: I'm trying. Actually, it's easy because I was very impressed by those presentations. We need to gather the data together in a form that is readily available to the public, and to the Congress, and to other legislatures.
Dr. ES: We also need it for ourselves.
Dr. RS: Yes. We need to encourage this kind of research. The methodology of outcome research should be part of the core curriculum at our institutes.
Dr. ES: What do you think the chances really are for parity in third party payment?
Dr. RS: It's going to be a very hard battle.
Dr. ES: Do you think that the implementation of the Gaskill Proposal will hamper third party payments insofar as we are now less of a medical organization?
Dr. RS: That's very hard to predict, but I certainly hope not. We are also taking initiatives in other areas. The Committee on University and Medical Education, chaired by Bob Michels and now by Arnie Cooper, is reaching out to departments of psychiatry which don't have analysts on their faculties. If they are in locations where there are no institutes, we are sending visiting professors in analysis.
Dr. ES: I didn't know that. How many departments of psychiatry have no analysts?
Dr. RS: I can't answer that, but I do know that more than a dozen have approached the committee, and eight have been visited thus far. The Committee on University and Medical Education is also trying to present analytic ideas in colleges and universities in an accurate and factual way. In many universities, as you know, their view of analysis is something Freud wrote in 1905. It is as though he had never had another thought, and as though analysis has not progressed since that time. The Program Committee under Paul Dewald has begun to have single theme programs in which one topic is studied from a number of perspectives on different panels. It is my hope that those single theme programs will result in a monograph series similar to the one from the Workshops for Mental Health Professionals. Chuck Rothstein has done a brilliant job coordinating those workshops. I think that our Journal, edited by Ted Shapiro, continues to be one of the outstanding psychoanalytic publications in the world. The Psychoanalytic Index, put together by Paul Mosher and generously given by him to the Association, is now available. It contains the references for all psychoanalytic writing from 1920 to 1986.
Dr. ES: What are your thoughts about our relationship with the American Psychiatric Association? I guess I'm particularly interested in what you think will happen in this area as the Gaskill Proposal is implemented.
Dr. RS: I think we should feel very proud to be in the American Psychoanalytic Association at this time when the President of the American Psychiatric Association, George Pollack, is an analyst. The current President-elect of the American Psychiatric is Paul Fink, also an analyst. Another analyst, Herb Pardes, is the Vice President, and is now a candidate for the office of President. I think we should be proud of the contributions that analysts are making to American psychiatry. The task for the American Psychoanalytic Association is to find ways to work very closely with the APA, but at the same time to recognize that we are two completely separate organizations. While there are many interests that we have in common, there are also interests that are separate and different. Those have to be respected on both sides.
Dr. ES: Please be more specific.
Dr. RS: Well, to be very specific, throughout this entire debate about nonmedical training, I have never believed that it is an either/or situation. I believe that APsaA must maintain its historical links to medicine and psychiatry. At the same time, multiple identities are possible in psychoanalysis. It's not a matter of choosing one or the other. Psychoanalysis has, from the beginning, had very close ties to medicine and psychiatry. Freud was a physician, a neurologist, a psychiatrist. He always believed in the power of biological forces both in his understanding of drives and also in his belief that as time passed we would discover biological factors in mental illness and psychic life. And, increasingly, this has happened. But from the start, analysis has also had very close ties to psychology, the social sciences, the humanities, and the arts. Psychoanalysis as a science and as a profession encompasses many disciplines. I believe it is important for the American Psychoanalytic Association to recognize and maintain close ties to other disciplines as well. As to specifics, analysts have had more input into the revision
of DSM-III than we had into the original DSM-III.
Dr. ES: You are really saying that you don't feel that we are being kept out by the APA. The issue is that we've been tending our own garden and not paying attention to the wider world.
Dr. RS: That's right. I believe that we will also have to take responsibility in the struggle for reimbursement of long-term therapy and analysis. I don't believe we can expect the APA, or any other organization, to fight that battle for us. It is our battle. We have to do more outcome studies, collect scientific evidence, and put forward the case for psychoanalysis.
Dr. ES: What is happening to our relationship with the International Psychoanalytical Association?
Dr. RS: The American Psychoanalytic Association is a very important part of the IPA, but it is not the only part, and the IPA has grown. The American, I think, has recognized the growth of the IPA.
Dr. ES: I heard a rumor in December that, since the rules of the International have been changed, some institutes may drop out of the American and become direct members of the IPA.
Dr. RS: For the first time that's possible.
Dr. ES: The rumor said that it was probable.
Dr. RS: Well, that rumor has been around from the beginning. Since 1938, the Regional Association status of the American within the IPA has meant that we could establish our own Board on Professional Standards and accredit our own institutes. These institutes would automatically be accepted by the International. No other society within the International had that right. I happen to think that that arrangement was a good thing for American psychoanalysis and for the International. The other aspect of the Regional Association status was that no institute or society in the United States that was not part of the American could become a member of the International. It's that aspect of the original status which has been modified. So, for the first time, institutes and societies in the U.S. which are not part of the American and which meet the qualifications and standards of the IPA can become members of the IPA. It is true that an institute or society which was unhappy with the American could decide to leave and apply directly to the International. I hope that doesn't happen. I don't believe the IPA would welcome such a thing or that they would create a situation where they would encourage such a thing to happen. But it does mean that the Executive Committee, the Executive Council, and the Board on Professional Standards will have to be particularly attentive to the needs of our affiliate institutes and societies, respectful of those needs, and responsive to those needs.
Dr. ES: But not lowering our standards?
Dr. RS: No, attentive. In fact, being attentive to local needs and concerns will help to maintain standards. And speaking of increased communication, it is also vitally important for us to maintain close ties with our analytic colleagues in this hemisphere. We have appointed a liaison representative who has personal links to Canada and to the Canadian Psychoanalytic Society (Ed Joseph) and we have done the same with the Latin American Societies (Gunther Perdigao).
Dr. ES: What about the relationship between the American and other psychoanalytic organizations in the U.S.? The Academy, the Freudian Society, the W.A. White group and so on? Do we have any official contacts with these other analytical organizations?
Dr. RS: Not at this point. I think that the next President, the next Chairman of the Board and the next Executive Committee will want to think about the whole issue of broader and wider contacts between the American and other analytic groups. It seems to me that's an issue for the future. I don't really know how to establish those contacts or under what circumstances they should be undertaken, but I do believe that the relationship of the American to other analytic groups in this country should be given serious consideration. I have worked during these two years to solidify and deepen our contacts with both the APA and the IPA. That has taken a lot of time. I also think that some kind of direct liaison with our European colleagues would be of value. In other words, I think the more direct communication we have with other analytic groups, with other analytic societies in this country and around the world, the more psychoanalysis will benefit.
Dr. ES: How many of your other activities have you had to give up to be President? Where did the time come from?
Dr. ES: What haven't I asked you?
Dr. RS: I think we have covered just about everything. There are difficult times ahead for psychoanalysis and maybe in some ways we are going to have to go back to sacrifices that were necessary in the early days. Psychoanalysis is a powerful treatment, unequaled for certain conditions, but we need to recognize that there has been an explosion of knowledge in our field. We now are aware of multiple treatments for many conditions. I believe that in the future we are going to find ourselves conducting analyses in conjunction with many of these other treatment modalities. In fact, I think we are going to find that treating some patients with psychopharmacology will render them more amenable to psychoanalytic treatment.
Dr. ES: So we are also going to have to know about those other modalities and perhaps do more complete evaluations of our patients than we have done in the past?
Dr. RS: Absolutely. We are going to have to be informed about them and know when they are indicated. We are going to have to know who to call in for a consultation and we are going to have to know how to conduct analyses in conjunction with those other modalities and with those other individuals who are expert in the use of those modalities. We also need to maintain the conviction that, for the patient who truly needs analysis, there is no treatment that will ever take its place. And, we also need to do the outcome studies that will support that conviction.
Dr. ES: Dick, thank you very much. It was worth waiting 20 months for this interview.
Dr. RS: Thank you, Elise.