Ostow: Bernie, you are generally known as the quintessential psychoanalyst—child analyst, adult analyst, institutional and organizational analyst, concerned not only with your patients and with your discipline but with the psychoanalytic community in general. Your recent term as president of The American seems but a logical extension of your career in analysis. However, I don't know that many of our colleagues realize how many interests you have had in cognate disciplines, how diverse your experience has been, and how analysis has turned out to be the zenith of your scientific development.
Pacella: Well, let me begin at the beginning of my medical career. I was graduated from the University of Colorado School of Medicine in May 1935, just before my twenty-third birthday that July. Following a rotating internship in surgery and internal medicine, I became a resident in pediatrics at Kings County Hospital in New York City for a year and a half. Earlier I had anticipated going into neurological research, but I became interested in child psychiatry, and so decided to establish a base by first taking training in pediatrics. My interests then proceeded to pediatric psychiatry, and I went to the New York State Psychiatric Institute at Columbia for a fellowship in research, for a year and a half in 1938 and 1939. This was followed by a psychiatric residency at the institute, following which I received a permanent appointment as a full-time research psychiatrist around 1941. I remained in the New York State service on a full-time basis for about ten years. Because of my pediatric background and experience in child psychiatry, I was made chief of child psychiatry and was given the title of associate research psychiatrist at the Psychiatric Institute and Columbia University. While working in clinical child psychiatry and in child psychiatric research, I devoted a reasonable part of my time to experimental neurology.
Ostow: Is that when you did your work on irritation of the monkey brain?
Pacella: Yes. I was doing neurophysiological research with Eugene Barrera, who was then director of research at the Psychiatric Institute. Barrera had done some neurosurgical work with Wilder Penfield, who was then concerned with the pathophysiology of epilepsy, and Barrera taught me neurosurgical technique for the monkey brain. When he became professor and chair of psychiatry at Albany Medical School and resigned from the institute, I took over and continued his work for several years, working on a project on focal epilepsy in the macaque.
Ostow: And when did you start studying electric shock therapy?
Pacella: In 1939 Kalinowsky arrived at the institute from Rome with plans furnished him by Cerletti and Bini, of the University of Rome, for an electric shock therapy machine. W.E. Rahm, an electronics engineer in our research department, constructed the first electric shock machine in the U.S. on the basis of those plans, and soon the first treatments using a machine made in this country were given. The first studies made in the U.S. of the neurological and neurophysiological effects of ECT on the brain were conducted in the main by myself and Barrera. The clinical studies included the psychiatric teams at the institute from 1939 to about 1945.
Ostow: When did you become an electroencephalographer? The American Electroencephalographic Association was established in 1937, and you, I believe, were a charter member.
Pacella: Yes, and if I recall correctly, you too were a charter member, and wrote one of the first books on EEG. I studied with Hans Strauss, who was in charge of the EEG department and who later moved on to Mt. Sinai. When he left, I was assigned to the institute's EEG department in addition to my other duties. Before the Neurologic Institute acquired an electroencephalograph, we did EEGs for the entire Columbia University Medical Center. Before I left my full-time position at the Psychiatric Institute, I had operated on a considerable number of monkey brains, studying both the vestibular apparatus and the nature of induced epileptic seizures in the monkey. When Margaret Mahler arrived in this country, we asked her to join our staff as a consulting child psychiatrist, to conduct our conferences and do some clinical research. Hers was one conference that I always attended. It was Mahler who urged me to undertake psychoanalytic training, and she was insistent that I apply to the New York Psychoanalytic Institute, which accepted me as a candidate. In consequence, I altered my career and resigned my full-time position at the Psychiatric Institute so that I could devote more of my time and attention to psychoanalysis, clinical child psychiatry, and child analysis.
Ostow: So your initial interest in psychoanalysis was child analysis? And while all of this was going on you were also working in a private hospital?
Pacella: I had a part-time job at West Hill Sanitarium, a private hospital in Riverdale. After regular working hours, I would go there to supervise the activities of the staff and make rounds. The first electric shock therapy administered in a private psychiatric hospital in the U.S. was done at West Hill by me and a team of assistants.
Ostow: And then Regent Hospital?
Pacella: Regent Hospital was a general hospital owned by several persons and occupying two floors of a sixteen-story doctors cooperative building. I had purchased a small office in the building in 1952. In about 1962, new codes required that the hospital widen the halls and make other alterations. Since this was impossible to do, I was asked by the owners if I could arrange to have Regent Hospital operate as a twenty-four-bed psychiatric hospital, and I obtained a license for this operation from the New York State Department of Mental Hygiene in about the same year.
Ostow: How did you manage to integrate that with your other work?
Pacella: I found a medical director to run it. He was conscientious and an excellent administrator, so I didn't have much to do with it, except to determine policies of treatment and administration, make regular rounds, and hold case conferences.
Ostow: Who was it who said you were the best psychiatrist in New York City? I remember reading that in the New York Times.
Pacella: It was Bishop Sheen. I had a patient in analysis—a very prominent Catholic who knew the bishop very well and had been referred by him to me for therapy. But at the very same time the monsignor (he was not yet a bishop then) was saying in his very popular TV broadcasts, “Don't get on the couch, get on your knees.” His brother, Dr. Tom Sheen, was a member of the St. Clare's staff and knew the work I was doing, developing an inpatient psychiatric unit at the hospital. I would meet the bishop at various other functions in New York, and he always seemed friendly and willing to discuss confidential matters concerning diocesan activities. When the controversy with Dr. Frank Curran occurred over the “Don't get on the couch, get on your knees,” remark, the bishop replied that he was not against psychiatry and psychoanalysis, and that he even referred patients to Dr. Pacella, the best psychiatrist in the city. When I went into the Psychiatric Institute the next morning not having read the paper, everyone was bowing to me, much to my amazement. Then somebody showed me the article in the Times, which proved to be quite embarrassing for me.
Ostow: Which of these various interests have given you the most gratification? Would you say you enjoyed them all? And if you had to do it all over again, how would you sculpt your career?
Pacella: I would stick with child analysis. I always had the feeling that child analysis was what I would like most. I enjoyed working with the kids, especially the five- and six-year-olds. That's really what I'd like to do. But at that time I had too many diverse interests and curiosities.
Ostow: Can you say anything about how your identity as an analyst has influenced your personal life?
Pacella: Well, I had so many diverse interests that it took some time for me to develop my identity as an analyst. I was a little distant from The American initially and had very little interest in participating in its activities or those of the American Psychiatric Association. My identity with The American actually became strong after some years working with Mahler, with “Mahlerian” colleagues in Philadelphia, and especially with my close colleagues in the Psychoanalytic Research and Development Fund.
Ostow: Have any of your children followed you into analysis?
Pacella: No. I have four children. The eldest is Karen, a physician married to Dr. John Oldham, director of the New York State Psychiatric Institute and a training and supervising analyst at Columbia. Karen works full-time at Columbia Presbyterian Medical Center as an internist. My next is Richard, an attorney specializing in tax law and international law, and practicing in New York. The next is Madeline, a dietitian living in Maryland. Her husband, who is attached to Houghton Mifflin, the publisher, once informed me of an interesting and significant fact—namely, that books introducing new techniques in teaching, or deviations from presently accepted standards of thought, practice, or education, will usually be distributed first in the West, particularly California, and if successful there will then be distributed in the East. In other words, new innovations will first be tested in the West, especially California, suggesting that people there are considered more responsive to new things. The fourth child is my younger son, Bernard, Jr., who is an otolaryngologist and head and neck surgeon on the faculty and staff of Cornell University School of Medicine. He is an assistant clinical professor there. I feel very fortunate in having four such productive and creative children, who are dedicated to their work and to their families.
Ostow: It's striking to realize how active and involved you have been in so many diverse fields. And yet you have always given the impression of composure and relaxation, a quiet dignity. I've never seen you agitated or excited, aroused or angry. I've never heard you make a negative comment about anybody. Can you tell me how your personal background contributed to these characteristics?
Pacella: After years of analysis, I found that I can't answer that. Probably genetics has much to do with this.
Ostow: How did you develop an interest in religion?
Pacella: My paternal grandmother played an important role in my development from the age of ten to about sixteen, when she died as a result of a fire in her apartment. This affected me deeply. I still have strong memories of her taking me to church on New York's Mulberry Street when we moved there from Toronto when I was about ten. We lived for a few years with relatives on Mulberry Street near Grand, and my grandmother attended church every day. She spoke to me only in Italian—she could not speak English—and I recall responding mainly in English. I seemed to be her favorite, and she insisted on taking me to church at least once a week. She
often confided in me that I was the only family member to carry on the name of Pacella and that it was very important for me to be dedicated to Catholicism and to becoming important. Strangely enough, it has always seemed coincidental to me that during the earlier years of my work in psychiatry, in the 1950s and 1960s and the earlier period of my psychoanalytic work, I was involved in activities that were related to religion and Catholicism. For instance, during the period when pastoral counseling was developing, the American Psychiatric Association asked me to chair a Committee on Religion and Psychiatry, charged with exploring the many contiguous areas of religious beliefs and practice, in relation to the practice and concepts of psychiatry. I established many contacts with religious leaders of different faiths, held many group discussions, and at the same time supported the development of training programs for pastoral counselors. I was asked to be a consultant by the Archdiocese of New York and was appointed by Cardinal Spellman to a Committee on Catholic Divorce. At the same time, I was contacted by Monsignor Fulton J. Sheen (later to become Bishop Sheen) to consult with certain persons whom he had converted to Catholicism, and would often discuss with me some of the difficult situations he experienced in the archdiocese. My further involvement with religion and psychiatry occurred when I was asked to be director of psychiatry at St. Clare's Hospital in New York. I accepted this, in addition to my regular duties at Columbia University and St. Vincent's Hospital, where I was an attending. A number of other situations developed as a result of my involvement in religion and psychiatry, such as being asked to accept the chair of psychiatry and psychology at Catholic University in Washington, and to chair the department of psychiatry at the Stritch Medical Center of Loyola University School of Medicine. As I look back, I am surprised to see a “distinct tether” from my grandmother relationship in my subsequent activities in religion and religious organizations, regardless of what the deeper meanings may be.
Ostow: I understand that your parents came from Europe to New York, and then migrated to Toronto.
Pacella: Yes. Then they returned to New York when I was about ten and my two sisters were five and fifteen. We were all born in Toronto.
Ostow: What was your father's occupation?
Pacella: It was varied. He tried to be a singer when he first arrived in New York at the age of sixteen or seventeen. He was crazy about Enrico Caruso, but he only got as far as singing in the chorus. So he set up a music shop. When I was attending elementary school, for a while I had to play records of Italian folk tunes and opera all day Saturday in my father's music shop in Little Italy. I became familiar with all of the Italian folk tunes and operatic classics. We lived with my cousins on Mulberry and Grand, and I became part of the neighborhood gang. But we were not violent. Occasionally one or two of them would threaten Asians if they crossed Canal Street, the unofficial border between the two ethnic neighborhoods. So finally I said, “What the hell are we throwing rocks for? Let's be peaceful.” So they agreed, and they elected me boss.
Ostow: Let's get on to more professional matters. Everybody's talking and writing now about the future of psychoanalysis, so it's no longer a new subject. As Victor Rosen used to say, “The future isn't what it used to be.” But where do you see analysis ten, twenty, fifty years from now?
Pacella: I will borrow from Freud: psychoanalysis is a science of the mind, a research tool, and a therapeutic tool. I will confine my comments to the application of psychoanalysis to the treatment of mental, emotional, and behavioral disturbances. I think socioeconomic factors will partially shape the way we will use psychoanalysis as a therapeutic tool. I'm not sure whether there's any scientific evidence that says four or five times a week is necessarily more effective than two or three times a week. We don't actually know, but I think that the sense we have from our own personal experience is that we usually have more effective control of the therapeutic process when we see the patient more frequently. Economic costs, social pressures, and research may force us to find and develop techniques
that are shorter and less prolonged than those we employ today. The concomitant use of medications may find increasing acceptance by the psychoanalytic community, in addition to the complementary use of techniques employed in psychotherapy.
Ostow: Do you envision that fifty years from now there will still be a discrete, identifiable analytic profession?
Pacella: I think psychoanalysis will still be identifiable when it comes to basic principles, but when it comes to actual professional practice and procedures, I think it may be modified. Fifty years from now, I suspect, treatment will be a mixture of analytic and other psychological techniques and interventions, probably employing new (or even old) medications.
Ostow: How do you react to the observation that so many psychiatric conditions that in the forties and fifties we considered primarily psychogenic are now (a) responsive to medications quickly and cleanly, and (b) seem to be at least partially genetic in origin. Obviously, affective disease and schizophrenia are meant here, but also the various anxiety disorders and obsessive compulsive neurosis. One after another, various mental disturbances are responding to organic therapies and are demonstrably familial. How should that orient our thinking about these things? Fifty years ago we thought that everything was psychogenic, and that only analysis could make much of a difference.
Pacella: I must admit that I never felt that there could not possibly be some chemical agent that could affect our psychic function in such ways that could reduce or eliminate the symptoms caused by conflict and by developmental problems in psychic development. I always remind myself of Freud's comments that chemical agents might do the trick.
Ostow: Freud made that comment twice, first in the New Introductory Lectures in 1933 and again in the Outline, published just after he died. He wrote that in 1939, and it was not fifteen years later that the first chemical agents became available.
Pacella: I think too many of us forget that. The symptomatology created by developmental problems or genetic factors can be alleviated by chemicals, and as a result of that alleviation we are more able to explore behavior patterns, including those that result from conflict. In other words, we may not understand the conflicts without analysis, but certain conditions may be improved by chemical agents with or without analytic understanding.
Ostow: We always assumed, you and I, while we were students at the New York Institute, that if only you understand what's happening, then you have the power to cure it. I think that that belief has been modified for most of us over the years.
Pacella: I agree completely. Understanding alone is not necessarily so powerful that it can overcome all the pathology that has developed over the course of years.
Ostow: Other than institutional changes, what would you recommend as the agenda for psychoanalysts at the present time in terms of our survival as a profession, and the survival of psychoanalytic knowledge?
Pacella: I think it is most important for us to look constantly beyond the horizons of our present psychoanalytic concepts and practice constraints. The history of any science would tend to support that position. I'm rather impatient with those who feel that we must seclude ourselves in the citadel of current conceptions. Most of us are aware of Freud's comment, “The advance of knowledge does not tolerate any rigidity.”
Ostow: How do you understand the resistance of analysts to innovation?
Pacella: There may be an historical basis for it. The early analysts were very much concerned about “wild analysis” and varieties of “short cuts” by active interventions. It is possible that excessive caution in this regard tends to foster a rigidity against innovative thinking. In analytic work, if we concentrate only on dynamic change, to the relative exclusion of “therapeutic effectiveness,” we automatically foster a rigidity of theory and technique, and the avoidance of research and open-mindedness. However, in most organizations, if structure and function are highly organized, any deviation from long-used procedures will occasion a resistance to change. This certainly applies to classical technique. But we also see this in systems of treatment in other fields and other organizations. However, it is probable that it was necessary very early on to prevent “wild analysis,” in order to give analysts time to practice and study the scientific and therapeutic importance of psychoanalysis by the classical method. At the same time, it now is necessary to explore how we can more actively adapt psychoanalytic understanding to the delivery of mental health care to patients in our present socioeconomic environment and in the future. This is an absolute necessity.
Ostow: I asked you before what initiatives we should take on our own, rather than waiting to be passively forced into certain modalities by external circumstances.
Pacella: First, we must adapt our psychoanalytic techniques more directly to the alleviation of emotional, behavioral, and mental symptoms. This does not mean to discard the classical technique to which we presently subscribe. But we must explore methods of applying technical psychoanalytic knowledge to the treatment and care of large segments of the population who can benefit from short-term treatment and less frequent visits. This means, first, greater attention to the possibilities of psychoanalytic understanding and the use of other forms of psychotherapy in conjunction with analytic procedures and, for the psychoanalysts with medical degrees, exploring the careful use of conjoint therapy with pharmacological agents, and even varieties of physical rehabilitation procedures in certain instances. I would urge the membership of The American, and psychoanalysts in general, to espouse seriously their assumed task as health providers.
Ostow: Ours is not primarily a medical specialty?
Pacella: I can't conceptualize psychoanalysis as a primarily medical specialty. We have to consider that people from disciplines outside of medicine can be trained to deliver psychoanalytic treatment as competently as physicians do. However, psychoanalysis can be a subspecialty of psychiatry, just as it can also be a subspecialty of psychology. However, a psychiatrist who is a psychoanalyst may more effectively treat the more intensive forms of neurotic mental illness and characterological disturbance, and may acquire a greater depth of understanding of mind-body issues, prescribing medication when needed.
Ostow: What should we do about that, and how should we go about it?
Pacella: The way we could go about it is to encourage more research into our methodologies. We have not adequately researched our relationships with other varieties of psychological treatment. We have kept our technique restrained and restricted. Instead we should open our minds to other forms of psychological therapy in combination with psychoanalytic work, and to whatever pharmacological agents are demonstrably helpful. If transference issues or problems arise as a result of these ancillary treatments, they should be looked upon as a positive development to be analyzed rather than evaded. Our primary concern should be the effective and efficient delivery of mental health care, adhering to psychoanalytic principles but not necessarily to “standards” that may have become anachronistic. I would like to add, however, that any significant deviation from “standard procedures” should be undertaken with prudence and good judgment. I am very pleased to see that many of the institutes and societies of The American are increasingly developing programs for the teaching of psychoanalytic psychotherapy, in addition to classical psychoanalytic training. This should expand the base of our training programs while at the same time facilitating studies of treatment efficacy. In addition, there has been an increasing tendency in the psychoanalytic community to pay some attention to the use of medications cojointly with analytic therapy. I believe, Morty, that you have been a leader in this endeavor, and I admire your courage and your devotion to this innovation in psychoanalytic and psychological treatment.