Perspectives on Leadership II: Health Care Economics and Psychotherapy in the Larger World

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Posted November 2, 2007

I have long felt that, in order to survive, psychoanalysis had to engage in the world around it rather than withdrawing into itself. For that reason I have been very much involved in my own particular profession of psychiatry (see “On Coming Together,” Election 2007 list 9/30/07) Every step of the way I was up front about being a psychoanalyst who felt that my psychoanalytic persona had much to contribute to who I was and what I was doing.

As president of the Cleveland Psychiatric Society (1978-9) I decided that the greatest barrier to access to mental health care for many people was lack of adequate insurance. After assembling a coalition (1983-91) I spearheaded lobbying for legislation mandating non-discriminatory coverage for mental disorders including addictive disorders. This eventually led to service on a legislature-mandated Ohio State Task Force on Mental Health and Substance Abuse Treatment Financing to study the problem and file yet another report (1988-9). It was clear that powerful insurance company opposition was based on ignorance as well as lack of demand for parity on the part of employers.

As a result I started a program of the Ohio Psychiatric Association to reach employers. Employers, after all, are the prime source of financing for half the health care economy in the U.S. They can tell insurance companies what they want in health insurance for their employees. We aimed to educate them about mental illness, its profound economic impact in the workplace if untreated, and the need for much better benefits to do so. We achieved modest gains with 20% of the employers and were leaders among a half dozen state psychiatric societies that mounted similar programs. That ultimately stimulated the American Psychiatric Association (APA) to beef up their attention to economic affairs and support the District Branches in such efforts, and I served on the Committee on Financing and Marketing (1986-92).

After that entrance into psychiatric politics I became president of the OPA in 1986 and then in 1988 one of its representatives in the Assembly of the APA. Here I quickly became visible as I fought to steer the pursuit of parity for mental disorders in health insurance towards coverage of all psychiatric disorders, not just those arbitrarily and simplistically defined as “biologically based.” After only three years in the Assembly I was nominated to be Speaker, almost defeated the incumbent Recorder, and eventually did go through the Assembly offices to that influential position of presiding officer.

After a year on the Board of Trustees of APA as Speaker (1994-5) I had a year off and then was elected for six years as Area Trustee representing the Midwest states (1997-2003). I was on the Board of Trustees during a tumultuous time for the APA: we wrestled with huge decisions involving a complete reorganization, two changes of Medical Director, selling the APA building on K Street in Washington and moving to Arlington, VA, declining membership for the first time ever, a financial crisis, and several very difficult legal situations involving terminations of top executives for cause. I played an active and constructive part in those debates. Fortunately the American Psychiatric Association has since recovered nicely from those critical times, but I know what it takes for a major professional organization to deal with crisis.

I was twice nominated for national APA office, first for Trustee at Large (1996) and later for Vice President (2003), running unsuccessfully against highly visible opponents, though I garnered a respectable percentage of votes. I also served on key policy committees such as the Committee on Universal Access to Health Care and the Task Force on Vision for the Future of Mental Health Care. A particular challenge was chairing a Task Force to Educate Members on Physician-Assisted Suicide, composed of five people with widely divergent views; our well-researched, balanced report was a hot potato that got quietly shelved.

Participating in APA leadership frequently gave me the opportunity to speak up frequently for the importance of a strong APA position in support of psychotherapy as a fundamental part of the psychiatrist’s skills. This led me to advocate successfully for a high-profile Commission on Psychotherapy by Psychiatrists, of which I became the founding chair in 1996. My broad vision for the Commission was to have it include representatives of all major fields of psychotherapy and to have an over-arching role in relating to all relevant components of the APA. Being on the Board of Trustees enabled my getting the green light to do so.

We reviewed APA practice guidelines and other documents for fair treatment of psychotherapy, worked for a more appropriate standard for the evidence base of psychodynamic psychotherapy, pressed for economic advocacy for psychotherapy by psychiatrists, wrote resource papers on documentation of psychotherapy, made much-welcomed presentations on teaching psychotherapy to the American Association of Directors of Residency Training in Psychiatry (AADPRT), promoted an innovative program for teaching psychotherapy early in residency, played a significant role in getting psychotherapy requirements strengthened in the criteria of the Residency Review Committee for Psychiatry, got APA to support guaranteed access to psychotherapy for psychiatric residents, studied mind-brain issues in psychotherapy, and educated APA members on the integrated use of psychotherapy and medications. The successor Committee on Psychotherapy by Psychiatrists remains an established component of the APA, of which I continue as a member.

In 2000, Dan Borenstein, an analyst who was then president of APA, appointed me to chair the newly created Committee on APA/Business Relations. This was a natural outgrowth of my previous experience with employers and my interest in economic affairs. With excellent consultation by a past Executive Director of the U.S. Chamber of Commerce, we established relations with key researchers in health care economics, human relations professional groups, EAP and Human Resource Professional organizations, and major corporations. We surveyed local coalitions that were developing an awareness of the devastating toll that mental disorders exact in the workplace, and played a significant role in designing their programs of intervention. We did exhaustive surveys of the health economics literature and published definitive reviews of the powerful evidence that supporting quality mental health care was good for the bottom line. Although we couldn’t attack managed care directly, we made employers alert to the impediments to appropriate care, including psychotherapy, that many managed care companies introduce and their employees complain about.

Our successful approach was based on partnership with employers; finding out their concerns, wants, and needs; devising ways to address them; and enlisting the participation of large, national companies in leading the employer community that finances half of the U.S. health care economy. Housed in the American Psychiatric Foundation, the Partnership for Workplace Mental Health has made itself a major resource for employers. A lively quarterly publication, Mental Health Works, conveys the latest information about mental health in the workplace and reports successful interventions by employers to facilitate employee recognition of problems and their prompt access to mental health care. It is also distributed regularly to the whole Congress of the United States. After six years of leading APA‘s business initiative, my term was up but I remain on the committee as a consultant. Our web site is

Today psychotherapy has a more secure place in American psychiatry. Today employers clearly want to address mental illness in the workplace and obtain effective treatment for it so as not to lose valued employees. And they emphatically want psychotherapy to be part of it. For the first time ever, a stand-alone mental-health-benefits parity bill has gotten through the U.S. Senate and is now headed for the House with bipartisan support and with the support of leaders in the business community.

I had a lot of talented and enthusiastic people on both of the APA committees I chaired in the last ten years, as well as excellent staff support, but the fact that they accomplished so much has been widely recognized as due to my leadership.
All of this work in organized psychiatry has given me a rich background for service in the American Psychoanalytic Association’s entry into these advocacy arenas over the past 20 years. I’ll pick up at this point in my next communication.

In the meantime, please don’t hesitate to call me at my office, (216) 381-5840, or home, (216) 371-4373, or communicate by e-mail at Thank you for your patience in reading through this long posting.

Drew Clemens

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