‘The Best Laid Plans…’

When I decided to seek election as APA president, I had a lot of ideas about what I would like to accomplish. Who was it who said, “Man makes plans, God laughs”?

My year was largely overtaken by forces I could not have ever imagined. COVID-19, long overdue demands to end structural racism, social distancing that put an end to in-person professional meetings, and the final months of a term of a U.S. president who did not appear to be acting in the interest of those of us who live in the United States—all these defined my presidential year.

Some described my presidency as “hijacked.” It’s not easy when one is overtaken by external events and must redirect one’s own agenda. But there is truth in that old saying that crisis begets opportunity, and the fact is that we accomplished a lot that was of great importance to APA, to psychiatry, and to our patients.

There is no way to think about this past year without taking into account the extraordinary racial reckoning that is taking place across American institutions, agencies, and businesses. Here at APA, I believe that reckoning has been real—not cosmetic—and will be ongoing. A total of 26 action items recommended by the Presidential Task Force to Address Structural Racism Throughout Psychiatry, under the leadership of Dr. Cheryl Wills, were approved by the Board of Trustees. These will, I believe, produce real and lasting change in all levels of APA governance, establishing equity, diversity, and inclusion as core organizing principles. It has also had ripple effects throughout APA; for example, DSM-TR-5, now being worked on, and many other books and journals produced by APA Publishing are incorporating the discussion of diversity, equity, and inclusion issues.

In a series of columns in Psychiatric News, I described the history of racism in psychiatry. It’s important to know this history to understand the context for the issues that face us now. I am proud of this contribution and appreciate the feedback that I received about them.

In January, the Board issued a historic apology for APA’s history of racism and for “enabling discriminatory and prejudicial actions within APA and racist practices in psychiatric treatment for Black, Indigenous, and People of Color (BIPOC).” The statement of apology—addressed to members, patients, their families, and the public—is accompanied by a document outlining specific practices and policies (including failures to speak out and protest racist practices) that have damaged BIPOC patients and their families dating to the time of APA’s founding. Both can be accessed here.

The work of the Task Force on Assessment of Psychiatric Bed Needs fulfills one of those goals I had before the pandemic took over our lives. Determining the right number of inpatient beds that a community needs is key to everything else that goes right or wrong in our mental health system: a shortage of psychiatric beds in public and general community hospitals results in overburdened emergency departments and outpatient services, and, in the worst case, patients become homeless or enter the criminal justice system.

But determining that number is not as simple as taking a census count of individuals with serious mental illness in the community. Getting to the right number of beds requires taking into account many variables, including the presence of community-based crisis services and the variety of settings that may already offer bedded psychiatric services—general hospitals, private psychiatric hospitals, forensic hospitals—as well as nursing homes and various kinds of residential treatment centers and settings (child and adolescent and geriatric facilities, rehabilitation facilities, group homes), some of which are not reportable to public agencies as psychiatric beds.

With the input of engineering and systems analysts, Dr. Anita Everett and her task force have worked through these and other complexities and succeeded in producing the first iteration of a usable model for determining how many beds any given community in the United States will need. I believe this is a contribution that will in time produce real change in our mental health system at all levels of care and treatment.

COVID-19 affected how my year as president was conducted. All meetings were virtual. While more than adequate to get business done, it’s just not the same. Lost were so many of the interpersonal aspects of belonging to a professional association such as ours. Hopefully, a year on Zoom will make us that much more grateful to be in each other’s presence when the pandemic is behind us.

Despite more, and often longer, virtual meetings, my fellow Board of Trustees members were present and hard working. There were positive, unintended consequences. The close and supportive relationship with Dr. Saul Levin, our CEO and medical director, was heightened by the way communications took place. Interactions with APA staff were more extensive and gave me a more deep-rooted regard for the excellent work they do.

APA’s advocacy work never ends, pandemic or not. I offered, on behalf of APA, important testimony on Capitol Hill, most particularly in successful opposition to psychologists being defined as “physicians” under Medicare. APA effectively worked on improvement of parity enforcement. The passage of the American Rescue Plan Act of 2021, the $1.9 trillion coronavirus relief package, includes approximately $4 billion in funding for programs that support the prevention of and treatment for mental and substance use disorders.

Also, we continue to argue for reform of Maintenance of Certification, one of the most contentious member issues (Psychiatric News). My presidential year also saw the creation of the Committee on Climate Change and Mental Health, in recognition of an issue that is going to be with us long after the pandemic is a memory.

All of us sense that the end of the pandemic is in sight. Let us be prudent and patient so that this hope is not premature; as of this writing (in mid-April) masks and social distancing are still with us. And the truth is that it is unlikely we will go back to the “same old, same old” that existed in February 2020. We have been through a remarkable experience, one that has changed us all. I am grateful to have been your president during this extraordinary year. Whatever the future “normal” looks like, I am confident it will include a better and stronger APA for our members and our patients. ■