One of the key factors in successful administration of a large national association involves the judicial use of implicit power. Failures can occur j o m aggressivity as well as jorn passivity, and too great an enjoyment of power can lead to maladaptive administrative practices.

Administering a National Medical Association: The Joys, the Sorrows, and Other Challenges Melvin Sabshin

What I have chosen to present here is a mixture of several themes that have recurred during my career as medical director of the American Psy- chiatric Association (MA). In part, I will be autobiographical in explaining some things that I have done in this role. The bulk of what I say will involve special aspects of being a clinician-administrator of a large national medical association. In particular, 1 will emphasize the role heterogeneity of this administrative position and the creative possibilities, as well as the problems that are inherent in such a post, including too much joy with the implicit power. My method will involve some case examples and illustra- tions of events that have occurred during my directorship. Ultimately, I hope that these examples will have some relevance for the reader and perhaps be a contribution to administrative theory and practice.

All organizations have special features, and many an administrator naively-but, occasionally, correctly-believes that his or her system is indeed unique. From my perspective, large national medical associations do have at least a few unique features. I am the manager and executive of an office with over 250 employees. While the divisions, departments, and offices in the APA are very interesting and heterogeneous in their own right, this part of my job closely parallels roles described by many of my prede- cessors who received the APA administrative psychiatry award. What is

This chapter is adapted from a lecture given to the 141s annual scientific meeting of the American Psychiatric Association, May 10, 1988, Montreal, Canada.

NEW DIRECTIONS FOR MENTAL HEALTH SERVICES, no. 49, Spring 1991 @Jossey-Bass Inc.. Publishers 31

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more special and complex is the executive function in relationship to a fluid and rapidly changing governance system of multiple policymaking bodies, under the leadership of newly elected national officers. Further- more, the national geographical system, of local branches and regional entities of the APA, affects the administrator profoundly. Relating to these systems and to the hundreds of entities outside the system constitutes the major task of my administrative position. Talents in one part of this com- plex field do not necessarily correlate with good capacity for problem solving in other roles. In addition, the classic question of the professionally trained administrator versus the clinician-administrator has some special meaning in this pluralistic type of administrative world.

Succession and the Replacement of a Revered Figure It is gratuitous to point out that the choice of a new executive may be one of the most important events in the history of any organization. The APA is no exception to this rule, and a thorough search was made by a board of trustees committee before my appointment in 1974. The board clearly specified its continuing wish for a psychiatrist to be the medical director, as the title implies. (I expect some discussion about this matter when my successor is chosen, although I predict that the preference for a clinician-administrator will prevail.) My predecessor was indeed a revered figure who represented the very best in psychiatric administra- tion, including his remarkable personal attributes of judgment and integ- rity. I shared in the general admiration of Walter Barton, but it is clear that my adaptive task involved helping to shape a new APA-without any denigration of Barton, and without exerting undue personal power. Fortunate, in this regard, was Barton's strong agreement with the new policies and with the general perception that a new historical period had emerged, in which the APA's improved capacities in government relations, public affairs, and other systems would be necessary. For an administrator to realize that a change should occur in his beloved organization is in itself a considerable accomplishment. During my first five years as medical director, I believe, I was effective in instituting a number of administrative, structural, and functional changes in this regard, and this continues up to the present. The administrative princi- ples and practices embedded in these developments have included selecting effective personnel, guiding policy deliberations without undue intrusiveness, organizing a structural system to deal with new kinds of offices and personnel, preparing the association for a period of rapid change, and building the membership components with appropriate oversight of these functions. In each of those cases, being a psychiatrist contributed to problem solving.

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Coping with Officers and the Governance Structure All administrators are accountable in governance systems; indeed, a substan- tial portion of the administrative literature deals with such coping. This pro- cess occasionally produces stark drama (for example, the replacement of the executive officer of the National Rifle Association, one rainy midnight, by the president of the association, in what amounted to a palace coup). More often, struggles are less dramatic, with protracted accumulation of tensions leading, in many cases, to the replacement of the executive. Barton (1987) has described his own succession to the MA medical directorship after the some- what controversial resignation of his predecessor, Matthew Ross. Ross’s tenure was relatively short, quite productive in the beginning and somewhat stormy at the end. Barton produced stability through his personage, his sound knowl- edge of professional issues, and his sound administrative practices. Perhaps because he had been president of the APA before his assumption of the med- ical directorship, he was exceedingly effective in dealing with its officers.

In national associations, election of officers, the length of the officers’ terms, and the roles, job definitions, and traditions of the officers as they are related to the administrator are highly relevant. In particular, the annual turnover of officers poses a series of frequently recurring adaptive tasks for all players in the system. The APA elects a new president each year and has had a constitutionally prescribed contested election since 1973. In contrast to meritocracies, where single candidates are nominated, contested elections have much less predictability, and this is especially important in a national election (rather than election by a representative body). APA staff, including the medical director, must be scrupulously neutral and fair. It was astonish- ing and almost devastating when Barton was criticized during the early days of the APA’s contested elections, for his alleged partisan activities. If there are significant differences between opposing candidates, the medical director must adapt to the winner and be able to work with her or him. Furthermore, in organizations like the MA, there may be inherent differ- ences between elements in the governance system. If our board and assem- bly are locked in struggle, the administrator should be a healer, in most cases, and be able to work with all elements. Finally, if there are regional differences or criticisms of national entities by district branches (or the other way around), the administrator is constrained to function as an integrator. This integration involves multiple groups within the APA, as well as over one hundred liaison relationships with outside organizations. In my case, I believe that I have been fair and equitable, but I have not been a passive participant. Absolute neutrality would be a fatal flaw, almost as bad as persistent partisanship. I have occasionally been a strong advocate, especially if I felt that a particular policy was important and correct and if the problem was insufficiently enunciated by others.

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Our presidents have varied considerably in their personality charac- teristics, styles of leadership, priorities, and points of emphasis. The admin- istrator must empathize, understand, and be helpful and yet not be an automaton. One important fact is change of the administrator over time, when the tenure involves not only accumulation of experience but also cumulative power. The rate of accumulation of power is, of course, hastened when the administrator is a respected professional in the field. This can be offset by cumulative struggles, wherein different entities and individuals build up a pattern of opposition to the administrator, especially if there is a perceived misuse of power. Even in the best circumstances, it is apparent that criticism of the administrator accumulates over time, no matter how effective he or she has been.

Should the administrator have a vote on any of the deliberative bod- ies? Obviously, the administrator should be articulate and not depend on a single minority vote in any governance entity. The administrator should be given the courtesy of the floor and also be responsive to questions and concerns of deliberative bodies. In the APA, the medical director has a vote on the joint Reference Committee, composed of three representatives of the board, three members of the assembly, and the medical director. The joint Reference Committee serves as both an afferent and efferent arm to and from a policymaking board and is almost as powerful as the assembly. I have found the vote on this committee to be useful in ways beyond its potential critical impact in the case of a board-assembly standoff. (Such standoffs have occurred very rarely.) It has become a vehicle for expected commentary by the administrator on matters relative to problems in imple- mentation of actions or regulations. It serves as a formal safeguard, for example, if commentaries have not been made at other levels of discussion. Voting power may be useful for functions other than those that involve any amount of power. It is important to note that being a psychiatrist (as compared to being a professional administrator who is not a psychiatrist) has implications for the power to influence decisions on a large number of policy issues.

Should the administrator have full authority in staff appointments? I believe so, with the proviso that there will be occasions when a membership search committee should be given responsibility for recommending candi- dates for key staff leadership posts. Some appointments are so sensitive that members’ input may be quite important. I have used such search committees on a number of occasions, and in over 90 percent of such searches I have followed the committees’ recommendations. There have been occasions when I have not done so, and that has caused some struggle and tension. Clearly, the power of negotiating salaries, space, and benefits may permit the administrator to exercise this power indirectly. At times, direct confrontation may be necessary, but it is to be hoped that skillful administration will reduce the frequency of its occurrence. One special

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problem is termination of employment in a national association, since each office can develop its own constituency as an advocate.

To what extent should the administrator serve as the public spokes- person of the association? In the APA, the president is given that responsi- bility and authority. There are variations in presidents’ interests and capacities in this regard, and one of the administrator’s important respon- sibilities is to ascertain the president’s wishes in this matter and adapt accordingly. By and large, this policy has worked out well for me. I am generally comfortable being in the background-but not always. There are also times when I must be the visible leader. Excessive narcissism in the administrator or in the president can quickly evoke a conflict. Indeed, administration in national medical associations requires individuals who do have control over their narcissistic needs. Control also implies the willingness and capacity to step in actively when that is called for, espe- cially for a psychiatrist knowledgeable about scientific and professional issues. One of my greatest joys has been visiting and speaking at our local district branches. To some extent, this has afforded me an opportunity to speak directly, visibly, and vigorously on policy matters. The capacity to be effective in such a complex and varying role is one of the skills that search committees and boards must assess carefully in selecting their administra- tor. Excessive need for power and personal visibility are deadly sins that soon lead to failure. Excessive timidity and incapacity to be visible and articulate are equally bad. The balancing of these traits and skills is an issue insufficiently discussed in the administrative literature as such and is worthy of more attention.

Dealing with Problems, Crises, and Catastrophes As with pilots, professional athletes, and diplomats, a fundamental test of the administrator’s ability occurs during stressful periods, anticipated or not. All organizations go through such periods; of course, able administra- tion should reduce the frequency and intensity of crises. Once again, good judgment and accurate assessment of problems are necessary for success. Failure to assess the severity of a problem is often a major flaw. Equally damaging, however, is exaggeration of the problem. To call each problem a catastrophe leads to paralysis and exhaustion. For psychiatry, which is often involved in controversies, this issue is heavily compounded by the tendency of some colleagues to see catastrophe everywhere and, in their exaggeration, to fail to attempt the strategic and tactical planning necessary to solve the problems.

During my tenure at the APA, there have been numerous examples of the problems just mentioned. I would like to cite two examples of occasions on which I sensed catastrophe and became exceedingly active. Indeed, in both cases, I was concerned that key leaders of the association did not

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perceive the extent of the dangers clearly enough. In the first case, general administrative decisions were involved; in the second, being a psychiatrist was exceedingly important.

In the first case, the APA board had taken a strong stance on not holding our annual conventions in states that did not support the Equal Rights Amendment. With our convention for 1981 scheduled in New Orleans, the APA first cancelled the meeting, then reinstated it at the New Orleans site, and then cancelled it again. The second board decision to cancel was made suddenly, in the absence of legal counsel, and was a passionate reaffirmation of the principle of equal rights. This was a highly visible issue that divided our members severely and involved two general referenda. As medical director, I was upset by the second cancellation. I brooded about it, consulted with our attorney, and, working with him and the president, arranged for a meeting with authorities in New Orleans.

Ultimately, I became convinced that our organization might incur severe fiscal liability if we upheld the second cancellation. With the partic- ipation of legal counsel and officers, I called for a review of the decision, and we decided to go ahead and meet in New Orleans. The decision was (and remains) controversial in many quarters. To some, the APA wrongly gave up on a principle, for fear that its fiscal status would be jeopardized. To others, the APA was wrong because it did not repudiate the principle but acted on the fear of legal and fiscal repercussions. (It should be noted that at the time of this decision, there was no real chance that the Equal Rights Amendment would pass, and this increased the tension.) Some APA leaders decried the decision, and one stated that it was worth the bankruptcy of the APA He predicted massive resignations because we were going to meet in New Orleans, and a different kind of dissolution of the organization. I am pleased to say that this did not occur. Nevertheless, this kind of problem remains a dilemma for me. We in psychiatry remain vulnerable to passion- ate stances on social policy, stances that can cause severe problems.

The second case involved the events surrounding the attempted assas- sination of President Reagan and the trial of John Hinckley, Jr., leading to the verdict that Hinckley was not guilty by virtue of insanity. For a variety of reasons, I had perceived this verdict early on as a firestorm and a genuine potential catastrophe for psychiatry. Indeed, reactions in the press and the electronic media were severe and went far beyond the usual criticism of psychiatrists’ testifymg in court and behaving in an adversarial fashion. Fundamental questions about the reliability and validity of our field were raised by many serious reporters and commentators. Even though the psy- chiatric testimony was unusually superior (albeit adversarial), the events touched a raw nerve and reinforced many stereotypes. (Indeed, I was present later at a hearing where attorneys representing an insurance com- pany that was trying to reduce its psychiatric benefits used the Hinckley case to show how psychiatric expertise was controversial and unpredictable

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and therefore not worthy of equal reimbursement.) The APA engaged in many damage-control efforts in the short run and took a number of longer- range steps to reduce the probability of a repetition. For example, I gave a lengthy interview to American Medical News, designed to reduce the hefty antipsychiatry reaction from colleagues in other branches of medicine. This interview expressed our genuine shock at the assassination attempt but also took up the problems of the insanity defense and rebutted arguments that questioned the fundamental validity of our field. After careful consideration, we took a leadership role in requesting modification of the insanity defense, working closely with the American Bar Association. Over the longer period, we intensified our efforts to publicize research advances in psychiatry, recognizing that general awareness of these advances might reduce our vulnerability to public outcry in analogous circumstances. This event led us to intensify all our public activities, and this is still occurring.

This episode could be amplified in many other ways, but I want to emphasize here the role of the clinician-administrator in dealing with such . a situation. Coordination of the integrated response after I had perceived the full implications of the danger was, I believe, facilitated by my under- standing the interrelationships among the multiple aspects of psychiatry. (Obviously, we in psychiatry are more vulnerable to this particular kind of problem than, say, otolaryngologists or pathologists are.) It should be noted that executive-to-executive cooperation with the American Medical Associ- ation ( M A ) was really helpful in this situation.

Dealing with New Technologies and New Complexities and Coping with Personal and Role Limitations In this section, I shall discuss the need for administrators (certainly includ- ing clinician-administrators) to be aware of and attempt to correct for personal limitations. It is trite to say that no current administrator can be universally proficient across the board. Large national medical associations drive this point home as they steadily become more complex and diversi- fied. My own limitations in computer technology and business administra- tion have become more telling as time has passed. Clearly, associations will need the new technology for internal and external communications, publications, and business operations and in helping our members improve their research and clinical practice. The next generation of administrators will have many more basic skills and more experience in this broad field, and I applaud that trend. What I want to emphasize here is the need to know one’s limitations and correct for them through good recruitment and reinforcement. Similarly, I wish to call attention to the complexities that the APA is now experiencing through its new subsidiaries and business corporations. There is enormous room for entrepreneurial leadership and aggressive marketing. I do not represent that type of administration, but I

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have learned a good deal about how to encourage these developments. Occasionally, my learning has come after serious problems, such as poor marketing of our publications, condescending treatment of AFA members by one of our nearly autonomous subsidiaries, or cavalier actions by one of our peer reviewers. Equally complex is the management of our frequent legal questions. Obviously, associations need effective legal counsel, and the APA has been fortunate in the work of Joel Klein and his associates. The penetration of legal processes deep into the heart of the AFA would be difficult to overestimate-from ethics appeals to real estate, from copyrights to liability, from antitrust to members’ mistrust, from annual meeting-site selection to advertising and a thousand other issues. At times, I have thought seriously about the need to have a lawyer as our director. For the near future, I still favor a psychiatrist, but the need for legal wisdom is moving closer to center stage.

Coping with Psychiatry’s Transition and Looking Toward the Next Century During the last fourteen years, both the APA and American psychiatry have changed dramatically. I anticipated some of the changes and played a role in them. The rapidity of developments has put special pressures on some of our members and given new opportunities to others. These issues have been widely discussed in the APA governance system and have affected many policy decisions. Nevertheless, through its continuity, my adminis- trative role has given me a great deal of responsibility for steering the direction of change over a longer range of time. In selecting me, the AF’A board said it wanted someone who understood the past but was also com- mitted to changes in the profession. That evolutionary transition has been the hallmark of my tenure. Clearly, there are some administrators who are excellent during times of revolutionary changes in an association; others are better at stabilization and status quo. I would rate myself highly as more effective in evolutionary change, in a manner that keeps the association relevant to a heterogeneous group of psychiatrists. From the beginning of my career in psychiatry, I resented the perception that we were divided ideologically into conflicting groups that never deigned to communicate with one another. I was also concerned about our assuming so many role functions that it was almost impossible for the general public to have a clear understanding of who we were and what we did.

During my tenure, I have worked hard to make the field more unified under the principles of empiricism, science, and objectivity. Part of that process has involved making the APA more attractive to academic and research psychiatrists, without losing our fundamental connections to clin- ical practice. Parallel to this effort has been the remarkable efflorescence of neuroscience. The rate of change is truly breathtaking but also brings prob-

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lems. Recently I attended a meeting where one speaker happily anticipated the incorporation of psychiatrists into neuroscience: psychiatrists, in effect, would wait at the laboratory doors and deliver the new products to a needy public. The speaker critically reminded the audience of Freud’s characteri- zation of neuroscience as of no greater importance than the walls of a telescope. From my perspective, both biological reductionism and vitalism are wrong. Like Eisenberg (1986), I cannot abide either a mindless or a brainless psychiatry. I believe that we must be conscious of the dangers of reductionism during this period of explosion in the biological sciences and must struggle against any tendency to lose our clinical acuities, our openness to psychosocial variables, and our humanism. To keep that deli- cate balance, while maintaining our communication with all shades of psychiatrists and attempting to define our commonalities, our boundaries, and our priorities, has been my chief goal during my tenure at the APA. It has defined my speeches at district branches, my part in organizational developments at the staff level (for example, in services, in education, and in research), and my participation in policy deliberations.

This effort has accounted for some of the greatest joys and sorrows during my tenure. Perhaps my greatest joy has been to witness the basic tendency among younger psychiatrists to assume a more balanced per- spective and be less ideologically driven. My greatest sorrow has been to witness the tendency of others to bring back the world of the 1950s: some hate the messenger who tells them that they cannot go home again. Those who struggle for a perfect solution, as an enemy of the good outcome, have also caused me grief.

By and large, however, there have been many more joys than sorrows. I still feel very lucky to have found a position that has afforded me so many unique opportunities. I have also been lucky enough to share these joys and sorrows with many close colleagues on the staff and among our members.

Because I wanted to be somewhat autobiographical here, I have empha- sized what I have done. I do not believe that I would have survived nearly this long if I had become too intoxicated with the joys and too needy of the credit for our successes. Gaining the APA’s award in administrative psychiatry has given me great pleasure. I am enjoying it and am grateful for it-in moderation, I hope.

References Barton, W. E. The History and Influence of the American Psychiatric Association. Wash-

Eisenberg, L. “Mindlessness and Brainlessness in Psychiatry.” British Journal of ington, D.C.: American Psychiatric Association, 1987.

Psychiatry, 1986, 148, 497-508.

Melvin Sabshin, M.D., is medical director of the American Psychiatric Association.