My answer to the question in this title is a resounding “yes.” As a psychiatrist, my expression of this is through the American Psychiatric Association. I have been privileged to support my field in leadership positions, but there are many ways to do it, at the local and state as well as national levels. When analysts get involved in the APA, they often rise to positions of influence; about half of the presidents of APA since 1980 have been psychoanalysts. But maintaining membership and paying dues are also vital expressions of support. To our colleagues in psychology and social work I would say that it is equally important that they be a presence in their own professional organizations, for reasons similar to those I describe below.
As active members of their local psychiatric societies or the APA, psychoanalysts have maintained a keen focus on dimensions of psychiatry that are vulnerable to current trends in a world dominated by medications, managed care, and symptom-oriented thinking. Analysts and like-minded psychiatrists with psychodynamic training carry the banner for the doctor-patient relationship, a developmental view of the person who has the illness, the vital role of psychotherapy in psychiatric care, privacy and confidentiality, and many other aspects of psychiatry that could easily get lost otherwise. The voice of analysts has been a rallying cry that has permeated the work of APA in recent years.
The APA has been a staunch defender of confidentiality and protection of patient rights in the 1996 US Supreme Court decision in Jaffee v. Redmond as well as more recent battles over the HIPAA privacy rule, often working in concert with the government relations representatives of the APsaA. In addition APA seeks the end of discrimination against the mentally ill in health insurance benefits and their management. A major investment in outreach to business leaders aims to shape the future of the privately funded health care system with an emphasis on Access to Quality Mental Health Care. APA has recently taken strong positions in opposition to “behavioral” managed care carve-outs.
Unfortunately, APA's government relations focus has had to maintain a heavy concentration on opposing state legislation that would allow psychologists to prescribe medication, a regrettably defensive posture but one we feel is increasingly crucial to patient safety as we learn more about the potential systemic effects and drug interactions of psychotropic medications. If more psychologist analysts were involved in their APA, one would hope that they would help to influence their leadership away from this dangerous pathway that pits the professions against each other instead of fostering collaborative scientific ventures and achieving common political goals on behalf of good patient care.
“My answer to the question in this title is a resounding “yes.” As a psychiatrist, my expression of this is through the American Psychiatric Association.”
The American Psychiatric Association has a very active research agenda, in which some studies are now focused on psychosocial as well as pharmaceutical interventions, particularly when part of an integrated program of care by a psychiatrist. In addition, APA establishes standards that influence the field worldwide, through its Diagnostic and Statistical Manual, its practice guidelines, and its recommendations about documentation of psychotherapy. The voice of psychoanalyst-psychiatrists has kept the practice guidelines from becoming totally skewed towards biological interventions, though constant vigilance is essential. The influential APA journals and books also show a resurgence of interest in psychotherapy. APA's Commission on Psychotherapy by Psychiatrists helped to reinvigorate psychiatric residency training in psychotherapy and to implement requirements to demonstrate competency in psychotherapy.
As development of DSM-V and its integration with ICD-10 get underway, psychoanalytic input will be essential to maintain a balanced viewpoint, even in the manual's purported totally descriptive approach that aims to be etiology-neutral. No longer keeping the personality disorders as a separate diagnostic axis is already the subject of heated discussion, with concerns about scientific integrity, the vulnerability of the multi-axial system to discrimination by insurers against personality disorders, and compromised care of patients with some personality disorders such as borderline. Considering psychoanalysts' keen observation of personality development and their particular advantage in treating these disorders, they must be part of the think tank that considers new diagnostic approaches.
Psychoanalysts are also needed in developing standards for the woefully short-handed field of child and adolescent psychiatry, where managed-care time constraints and the rush to medication have tended to undermine careful developmental history and study of the child's relations with his or her family as central bases for treatment interventions. If physician-analysts withdraw from the APA and the American Academy of Child and Adolescent Psychiatry, the influential scientific products of those organizations will be badly skewed towards a biological and symptom-oriented framework of clinical work with children.
An alarming trend in APA and other medical societies has been a fall-off in membership in the past several years. This reduces the dues income, the advocacy strength, and the credibility of the organization as being representative of a broad consensus among practitioners. Without raising dues, which have stayed level for six years, the APA Board of Trustees has drastically tightened the budget, downsized in various ways, and insisted on fiscal prudence to deal with diminished resources resulting from lower dues income and the current downturn in investment yields.
Norman A. Clemens, M.D. is Area 4 Trustee of the APA. In the APsaA he is a Fellow of BOPS. He is also president of the Cleveland Psychoanalytic Center.
A large part of the APA's membership loss seems to be in early career psychiatrists who are unmindful of the enormous amount of work that APA does for them and their chosen field. Involvement in their professional organization may be crucial to restoring these young psychiatrists' sense of pride and professionalism in their field, countering pressures from employers or third-party payers whose motivations are profit-oriented rather than patient-oriented. Analysts working with them in APA and its state organizations can help them appreciate a point of view that was not always evident in their training programs.
As our scientific advances point increasingly towards the confluence of mind and body, it becomes all the more important that those who treat mental illness not be fractionated. APA is the arena where psychiatrists with the whole spectrum of viewpoints and practice settings can come together for the common good of our patients and our professions. As a psychoanalyst, I can say that it is exciting and invigorating to carry forward our historic role in that arena.