In his column in the December 6 issue, APA President Paul Appelbaum, M.D., lamented APA’s declining membership and decreasing member participation, the number of members voting in APA elections dropping over the years from 60 percent to 31 percent last year. He mentioned the problem of alienation, not only among the membership but in the public at large, where the number of voters has similarly dropped. He spoke of a general withdrawal in America from civic activities, referring to sociologist Robert Putnam’s book Bowling Alone (once people bowled in leagues, now they bowl alone), where Putnam discusses the pervasive decline of "social capital."

In the world outside, following the failures of command economies and socially oriented ideologies (some giving rise under Hitler, Stalin, Mao, and Mussolini to the most terrible evils), there was a return once more to a free-market, democratic capitalism approach. This, however, has its own serious drawbacks. Not only has it failed seriously before, but once again we see a trend toward a reduction of things of value to material objects and an emphasis away from their intrinsic values to their usefulness as objects for exchange. This dehumanizing objectification, along with an amazing technology and its accompanying mechanistic orientation and with a reductionistic, value-free, triumphalist scientism, has resulted in alienation and a decreasingly contemplative, reflective, uninvolved, participant public.

Psychodynamic psychiatry has suffered severely, therefore, for it is concerned with the individual who speaks, makes signs and symbols, needs values and meaning, and has human needs for communication and involvement in the process of his or her own governance. Our free-market health care system does not provide that, and our profession, our members, and their patients see themselves progressively depersonalized, turned into objects of exchange in a world of omnipotent, value-free scientism and technology, helpless, powerless, subservient, resentful, not understanding what is going on, playing no role, insignificant cogs in a gigantic bureaucratic regime whose management is best left to experts and where one has little to contribute, but much to complain about.

This unhappy trend has inevitably entered into our APA as well, resulting in degrees of disaffection. To revitalize APA and its membership, we need a reaffirmation of and increased transparency, communication, and member involvement. We look forward to this in the regime coming in, with more openness and oversight in governance and management alike, where the medical director speaks regularly with the members, listens to and learns from them, and where the Board does similarly, questions the medical director actively, and speaks freely with the Assembly reps and the members about what is going on. The members must be more actively involved; otherwise, the vast bureaucratic machine will become even more bureaucratic and grind to a halt. We must never again hear the Assembly ask, "Why didn’t they tell us what was going on?"

There are good people in our governance and management. It’s a matter of orientation, and we need a resumption in APA of a function seen in psychodynamic psychiatry: the critique of culture. And perhaps this will catch on outside APA.

Dr. Peyser is an Assembly representative from the New York County District Branch and a former APA trustee.

APA President Paul Appelbaum, M.D., responds:

I appreciate the responses from Drs. Godbey, Cannon, and Peyser, and their points are well taken. In particular, many members do feel remote from the diverse activities of APA. And, as Dr. Peyser suggests, that may in part be due to trends well beyond the limits of our organization. How to dispel that sense of distance fully remains perplexing, but clearly better communication with all our members is essential. Jim Krajeski, M.D., editor in chief of Psychiatric News, our new medical director, Jay Scully, M.D., and I have talked about starting a regular medical director’s column that would inform members of the work being done on their behalf by the APA staff. I have thought for a long time that this would be an important link to our members, and I’m pleased that Dr. Scully agrees. APA now also has an e-mail list of 18,000 members, which we have begun to use experimentally. Given the sensitivity that people have to being "spammed," how best to use the list without annoying our members is an important question. And the APA Web site at

As for the focus of many APA leaders on internal reorganization (to which I plead guilty, as well), it is hard for us to remember that the structural issues that seem so important to us are obscure to most members and perhaps sometimes not nearly as critical as we believe. When they are, we have an obligation to explain to the members why, an obligation that I’m afraid we have not always discharged well.

Finally, Dr. Cannon wonders about how much a president of APA can really accomplish in a year, and whether there might be better ways of structuring the office. I will return to those questions in a subsequent column closer to the conclusion of my presidential year. ▪