Firestein: Dr. Firestein, can you tell us what you felt when you were elected Treasurer of The American three years ago?
Firestein: I felt it was very unlikely. Then again, it's unlikely that anyone of us analysts would be elected Treasurer, given that we have usually had no serious experience of a fiduciary nature. Like many, I self-selected for medicine and psychiatry in part to avoid that stuff. But “it” just circled around until it caught up with me.
Firestein: What do you consider your most useful preparation for a job like this?
Firestein: There was a book published not long ago in which the writer asserted that everything he really needed to know he learned in kindergarten. Well, I never attended kindergarten, so when I registered for first grade, I was placed in class “1A5.” This was called a “slow” class, but the kids knew the real truth: it was the “dumb” class. When our very experienced teacher taught us how to count, she knew well where we were at: each child had an envelope filled with kitchen debris—fruit pits that had to be lined up on our desktops. We counted them, added them, and subtracted them. That's when I learned that if you've got no more pits on your desk, you're really in trouble. This elemental lesson actually governs how we tend to the financial health of this Association. When we're out of dollars, we're “in the pits,” because nonprofit organizations generally cannot borrow. We do, however, have a mortgage for the purchase of our Central Office, which is a commercial cooperative space.
Firestein: Well, what's the life of the Treasurer like? I see your name on some memos that come my way, and on the masthead of meeting programs, but that doesn't tell me anything. What do you really “do,” if anything?
Firestein: The Association is many things, one of which is a financial body politic. That means that we have to collect dues and keep track of what we have spent as the year unfolds. Otherwise we can't know what we need to rein in, or when we have to consider a dues increment, an assessment for some special purpose, or when to try to raise funds from sources other than dues. Each month Helen Fischer and I cosign checks totaling seventy to eighty thousand dollars, each one of which arrives with its substantiating documentation. These are carefully prepared by our accounting department, and Mrs. Fischer and I scrutinize them a second or a third time.
We have to keep track of all the different categories of members and the timeliness of their dues payments. When members contact me because of hardship, I have guidelines for adjusting their dues in keeping with their altered circumstances. Members in the military or in full-time academic life are offered adjustments. We have to keep track of those situations—which are transient, which permanent—and those whose delinquency makes them eligible for suspension. We work hard to save every membership we can. Members who tender resignations are usually contacted by me in an effort to learn the facts and work out some arrangement.
We have an expanding category of Life Members. Most of those eligible to become Life Members do so, and are forgiven any further obligation for dues, though many are able to volunteer contributions of various sizes. We need to factor into our financial thinking all subtractions from full dues payments. The same attention must be accorded the additions to dues income occasioned by last year's delinkage amendment.
Firestein: Elsewhere you have referred to these activities as the Treasurer's “housekeeping.” Isn't that a demeaning way to refer to them?
Firestein: What I meant by “housekeeping” was that these activities are essential just to have an organization able to do anything. Everything costs money. But these activities are so presumptively important that they must proceed smoothly no matter what else is going on. They are as essential as the maintenance activities that all of us organize to keep our households operating effectively. We take this for granted, but it does require work.
We audit costs of our four annual meetings; of our site visits to institutes; even of the costs per issue of TAP, which for a year's publication is a significant cost center. We support the fellowship program for psychiatric residents, and hope to establish a comparable program for clinical psychology trainees. We also contribute to the Soviet Education Project, operate a student loan fund, and receive applications for support of a number of special projects. These all must be monitored.
Firestein: When do you manage to attend to all these items? And I'm sure that there must be even more than you mentioned.
Firestein: In between. In between everything, which is the only way any of the officers can operate. The American furnishes us FAX machines, which enormously facilitates keeping one another abreast of what we're doing. It eliminates “telephone tag,” a colossal time waster. Important as they are, though, these maintenance activities aren't the fun part of the Treasurer's job.
Firestein: The fun?
Firestein: The fun is working with other officers and members in devising ways to perform traditional chores better, and in making new projects happen. At the Central Office we have upgraded our ability to store and manipulate all kinds of data. Most of it is numbers for our accounting systems, tracking not only every member's financial persona, but our general ledger (which tracks every check that enters or leaves our coffers) and our outstanding bills. But that's not all: we are expanding our membership database so that we will have readily available the history of each member's participation in the committees and activities of The American. Easy access to such information will make the staffing of committees easier and will help to distribute appointments more evenly throughout the country. The officers had to choose our consultant and approve his contract, and continue to monitor the project as it unfolds. We're hurrying to join the twentieth century before we're into the twenty-first.
Firestein: With so many items costing money, I suppose the Treasurer has to be on top of everything?
Firestein: I do have to be, and for the sake of my sanity, I'd better be. If anything untoward occurs, one of the first questions is, “Did you know about this, and if you did, how could you let it pass?” I have to tell you that the task of monitoring is immeasurably helped by Helen Fischer, who alerts me to all manner of problem situations by phone or FAX. I don't know how else I could keep up. With so much paper crossing my desk from downtown every day—committee reports, memos, copies of important correspondence—I'm into my third system for keeping track. If I can't easily gain access to pertinent information, then all the paper in the world is useless to me. A lot of it gets read and discarded immediately.
In relation to big ticket items, like the data processing upgrade, I wouldn't dream of giving the go-ahead on my own. I share that responsibility with the other officers. For some things the Executive Committee shares responsibility with the Executive Council, which represents all the societies. That was true for a current project, the
addition to the staff of a person—for now designated the Practice Coordinator—for whom the budget cap voted by the Executive Council is $250,000. This is a very important initiative, one that many agree to be long past due.
Firestein: Do you believe the “catch-up” will be fast enough to reverse some of the unfavorable trends we read about every day? After all, the Clinton administration is promising significant changes in health care financing by the end of the first “hundred days.”
Firestein: Nobody can answer that question now. But we surely have to do everything we can to introduce some control into a situation that looks to be outpacing us.
There are some colleagues who believe we should turn our backs on the entire insurance universe and reserve psychoanalysis and long-term psychotherapy for the private market in medical care. In that market we can make our own contracts with our patients, and have the total privacy that we all agree is essential to psychoanalysis. That viewpoint is thoroughly respectable, but there are some problems with that approach. The percentage of the population in the totally private (unreimbursed) health care market, I read recently, is estimated to be not above 8%. Now, can a thriving psychoanalytic discipline be sustained from 8% of the population? And if it can't, how can we hope to attract candidates and replenish our ranks? To me it appears inescapable that we must continue to wrestle with the demons of health insurance.
Judith Schachter recently had a disarming conversation with Jay Cutler of the American Psychiatric Association. Among his comments was the assertion that long-term psychological treatments and cosmetic surgery are likely to be declassified as health care. This report made my blood curdle. Which brings me to another of our current big ticket projects, a co-morbidity survey of the memberships psychoanalytic practices. The details will soon be spelled out for everyone, but the purpose of the survey is to collect data to support the assertion that psychoanalysis is a medical treatment applied for the cure of serious medical problems—problems with significant societal impact, and not responsive to briefer treatments.
Firestein: You call that fun? What kind of a definition of fun is that?
Firestein: The fun is the special excitement of collaborating with colleagues all over the country in fashioning ways to address problems we never had to contend with before, and so have little experience to draw upon. The stakes for psychoanalysis are very high in this game, and the competition for a share of a limited national health care budget is intensifying all the time. So tune in two years from now, and we might have a better sense of where all our perspiration is getting us.