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Recalling a conversation with a psychiatrist trained in an earlier period, outgoing APA Medical Director Melvin Sabshin, M.D., described an exchange that captures the remarkable transformation of psychiatric practice since Sabshin assumed leadership of APA in 1974:
"He told me he preferred to diagnose his patients as Hamlet, Raskolnikov, or Madame Bovary, rather than using what has been called the ‘cookbook’ elements of DSM," Sabshin said.
Reflecting on the exchange, Sabshin added: "A psychiatrist who diagnoses a patient as King Lear is surely not practicing ‘cookbook’ psychiatry.
"But the question is: is he or she practicing psychiatry?"
The changing nature of psychiatry - the question of what, precisely, the practice of psychiatry is about - has been the theme of a remarkable chapter in the history of the profession, one that will be dominated by Sabshin’s name as by no one else’s.
His tenure as medical director of the oldest medical specialty society in America officially came to an end this month when he was succeeded by Steven Mirin, M.D.
Sabshin leaves behind a legacy of accomplishments that has dramatically affected the way members practice their profession - in ways of which they may be unaware.
In a span of two-and-a-half decades, he helped to steward psychiatric practice out of the shoals of ideology toward an evidence-based nosology, while managing to maintain multiple types of psychiatric practice under the "big tent" of APA.
In this way, he anticipated much of the tumult that would rock medicine and psychiatry beginning in the 1980’s, as payers began to direct medical care toward greater efficiency and accountability.
He also dramatically enhanced APA’s presence on Capitol Hill - bringing Jay Cutler on board as director of government relations in 1977 - while expanding the Association’s role in public affairs, economic affairs, and international affairs.
In addition, Sabshin was instrumental in conceptualizing and building a profitable publishing arm of the Association, the American Psychiatric Press Inc.
In all these ways, Sabshin has helped the organization grow from a relatively small, insular membership into a multifaceted professional society reaching out to American society - and the world - with the message that psychiatric treatments are demonstrably effective against a range of mental illnesses.
Divergent Ideologies
"In the early 1970’s we had conglomerations of divergent ideological groups," Sabshin recalled during an interview with Psychiatric News. "We had members with a strong involvement in psychotherapy, social and community psychiatry, and biological psychiatry. Each of these conglomerations had little involvement with the others.
". . .Part of my goal was to reduce the ideological dominance and to try to develop an evidence-based psychiatry," Sabshin said.
"Of course, ideologies are present in current psychiatry, but there is a growing unification."
The movement toward a science-based psychiatry was critical in helping members to navigate the economic pressures of recent years, Sabshin said, though some psychiatrists may not recognize or appreciate what their membership in APA has done for them.
"Managed care has altered psychiatry significantly, both the site and type of treatment," he said. "The new research has helped in coping with the new economic realities and, in this context, psychopharmacological work has become a centerpiece.
"APA anticipated many of these changes, and many of its activities have ameliorated the pressures on the average member," he added. "Yet the average member has felt beleaguered, and some do not appreciate what APA has accomplished."
The changes in the nature of practice have been reflected in institutional changes in the structure and governance of the Association.
"It was a relatively small, self-contained Association [in 1974], and one that needed leadership to grow and differentiate," Sabshin said. "I think I was a catalyst for that growth. . . . It’s worth noting that we did not have an Office of Research, and our involvement with education was relatively weak. I was very eager to see changes and I worked hard to build up both of those domains.
"In addition, I played a role in organizing the Office of Minority Affairs, the Office of International Affairs, and our multiple alliances overseas," Sabshin said. "I also took the lead in developing and organizing the American Psychiatric Press Inc."
He adds, "I think the most dramatic change has involved our assumption of significant roles in government affairs, economic affairs, and public affairs."
In all these ways, Sabshin helped to turn APA into a force to be reckoned with in American medicine and politics. At the same time, he considers himself to have been "blessed with superb deputies and senior staff" who have "made the difference."
Sabshin especially cited Jay Cutler as being "responsible for much of the respect accorded APA at all governmental levels."
Yet as APA has grown, there has been also the danger of "organizational sprawl," and Sabshin acknowledged that much of the expansion of the Association has been "unregulated."
Some within the organization have argued that fiscal and other pressures demand a smaller, "leaner and meaner" organization. Inevitably, this will mean elimination of some components and programs of the organization, unavoidably alienating constituencies. That is, perhaps, the defining dilemma faced by the new incoming medical director, who must balance the desire for a large and stable membership base with the imperative to streamline the Association.
For his part, Sabshin said he has always been an advocate of "the big tent" and of a heterogeneous organization. And he warns of the potential loss of membership that may occur through overzealous downsizing.
"A leaner, meaner APA with emphasis on a few high-priority areas will be much easier to govern and much more homogeneous but, paradoxically, is liable to be much weaker," he told Psychiatric News. "I have tried to develop a system of priorities allowing for concentration on major areas, without excluding many of the lower priority areas. To me, a ‘big tent’ covers many, many aspects of psychiatry, even if they don’t meet the criteria of ranking high on the priorities. . . . It is important that APA continue to support multiple areas of psychiatry and not disenfranchise a considerable number of members by showing disinterest in the variety of subjects and fields that might be in the lower 10 percent to 20 percent of interests."
He believes, furthermore, that his approach has returned dividends to the Association.
"There was a time 10 years ago when there was a strong effort to eliminate the Office of International Affairs," he recalls. "I fought that, and if I had not, we would not have had 4,500 international registrants at this year’s annual meeting in San Diego."
Prioritization of Treatments
It is not only the components and activities of APA that may require prioritization. Passionate advocates of treatment for the seriously mentally ill - especially the National Alliance on Mental Illness - have argued that APA and other groups should seek first coverage of comprehensive treatment for chronic disorders of a neurobiological origin.
If treatments for other, less disabling disorders are shortchanged, they argue, that is only the price of making decisions in the context of finite resources. Yet Sabshin said he believes there is a middle ground to be sought.
"My own judgment falls between the NAMI position and that of prior practice in this country," he said. "Twenty-five years ago, there was an underemphasis on the treatment of the most severely mentally ill. In part, this had to do with the relative incapacity to be genuinely helpful.
"Now we are at a time when we can provide much better treatment for depression, manic depression, panic disorder, and obsessive-compulsive disorder," he continued. "With schizophrenia, we can provide much better tertiary prevention by reducing some of the deficits that patients experience.
"My own opinion is that we ought to continue to treat people who have problems in the workplace and in their family lives, and to seek reimbursement for that treatment."
Though recent legislative efforts have focused on reimbursement for the most seriously mentally ill, "APA has been an important force for a somewhat broader perspective," Sabshin said. "And I am in favor of that."
Stigma
Given the long, entrenched history of stigma against mental illness, the fact that there has been any legislation to support parity for treatment of mental illness is remarkable, Sabshin said.
For the first time in history, he pointed out, a majority of the population in North America and Europe believe that psychiatric illness can be diagnosed and treated.
This broader, more humane understanding of mental illness, the recognition of its ubiquity throughout society, and the enhanced reputation of psychiatric treatments, are perhaps the greatest assets the profession can carry into the future, Sabshin suggested.
"For all the problems psychiatry has, it is a momentous thing that for the first time in history this relatively enlightened view is prevalent. At least in the United States, we have passed the stages of mythology and gross stigmatization."