Cancel My Subscription!

Looking over some of the correspondence that I have received as APA president, I was reminded of one of my favorite magazines, the Biblical Archaeology Review (or BAR, as it is referred to by the cognoscenti). Perhaps reading about the latest discoveries from digs in the Middle East is an esoteric passion. But BAR presents the information in a lively way, with wonderful illustrations and a genuine sense of humor. Moreover, the letters-to-the-editor section contains as uninhibited a selection of missives as you are likely to find in any periodical.

BAR’s letters section is probably best known for publishing a wonderful assortment of correspondence from its notably edgy readership that castigates the magazine for one failing or another and invariably ends, “Cancel my subscription!” The infractions being objected to range from articles that challenge the literal historicity of scripture to the magazine’s policy of allowing authors to choose whether to use A.D. (anno domini) or C.E. (common era) in reporting dates. Now one suspects that most magazines get such letters, but none of them flaunts their readers’ intemperance quite as outrageously as BAR. Indeed, several years ago BAR published a book containing the all-time best letters of cancellation that it had received, titled—how could it be otherwise—Cancel My Subscription!

Perhaps you can guess why BAR came to mind as I was perusing some of my correspondence. Some of the letters that I receive as APA president also end with a common refrain: “Cancel my membership!” Or sometimes they merely contain dark hints that the writer is thinking of leaving APA. What stimulates these responses? Pick an issue of controversy, and the likelihood is that someone has resigned or threatened to resign over it. Some years ago, APA’s position on abortion was a particular target of wrath. More recently, our actual or perceived relationships with the pharmaceutical industry have been a lightning rod. One recent letter writer alleged that APA was peddling a “biopsychiatric philosophy” that ignored psychosocial, economic, cultural, and traumatic roots of mental illness—something that would come as quite a surprise to the members working actively on the numerous components that address these issues.

A letter I received from a private practitioner complained of the dominance of “academic and corporate psychiatry” in APA, which nicely balances all the complaints I hear from colleagues in academia about APA’s singular focus on the interests of private practitioners. One member was upset that APA had not opposed the lifelong-learning initiative of the American Board of Medical Specialties that I wrote about in an earlier column. A retired member felt that he should no longer have to pay dues, while another member wanted APA’s support for a legal case in which he was involved. Some members are angry about the failure of the insurance company that provided professional liability coverage under the APA-endorsed plan. Another correspondent wanted reassurance that we were doing something to combat psychologists’ prescribing initiatives.

Almost uniformly, the issues that have gotten these members steamed up are important ones. Sometimes they represent issues about which reasonable people could disagree. Rarely, the letters reflect a disturbing level of entitlement, like the member who hadn’t gotten APA publications for a period (though he’d subsequently received them) because of a snafu with the information system and wanted his dues remitted for two years. Having been through this myself—somehow I was twice dropped from the publications’ mailing lists while vice president of the Association—I could empathize with the frustration, but not with the suggested remedy.

But in contrast to a decision to cancel a magazine subscription, leaving the professional organization for American psychiatry is serious business. Perhaps the most disturbing aspect of these communications is how readily some members jump to this extreme solution over almost any issue of contention. Unhappy with an APA policy? Feel the Association is neglecting some area of psychiatry? Write an e-mail or send a letter that somehow never got a response? Well then, clearly the thing to do is to resign from APA. Or is it?

Let me suggest an analogy. I am a United States citizen, born and bred. Sometimes our government does things that I think are wholly wrongheaded. I’m not talking about trivial matters, but about policies that may affect the lives and well-being of tens of millions of people in this country and around the world. Try as I might, I am unable to get the government to change course. I am angry and frustrated. What should I do?

As angry as I have been, I have never been tempted to renounce my citizenship and move to some other country. When I take a step back and cool down a bit, I am able to recognize that this country is a wonderful place, and the very government about which I am so upset protects me and my family, maintains our democratic system, and, for all its failings, carries out many policies that I wholeheartedly support. No single issue, regardless of its importance, could make me surrender my citizenship.

Similarly, I submit to you, no single issue should lead a member to resign from APA. In an association of 35,000 members, it is inevitable that some members will disagree with almost any position or action that APA takes. And, since we are governed by human beings, sometimes those positions or actions in fact will be wrong. However, there is no other organization that can represent the breadth of American psychiatry and fight for the things that are important to all of us. Without APA, or with an Association that is markedly reduced in size, psychiatry would be without a voice that commands attention on Capitol Hill, in the White House, at the regulatory agencies, in state legislatures, and in the courts. How will any of us—or our patients—be better off if that comes to pass?

For that matter, how will things improve if APA’s public affairs efforts aimed at educating the public about the reality and treatability of mental disorders disappear? Would we really be better off without DSM and the APA practice guidelines, or our Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry? With the compliance deadline for the HIPAA privacy rule just a few months off (April 14) for most health care entities, is the current work producing resources for members really dispensable? If there were not an American Journal of Psychiatry or Psychiatric Services, would we be better clinicians as a result?

It’s clear to me that the answer to all these questions is “No!” So I encourage you, next time APA does something that you wish we hadn’t, cut us some slack. No one is perfect, and it’s inevitable that an organization this big and diverse will sometimes go off in a direction that some of us will not endorse. When it happens, write letters or call your Area trustees, Assembly representatives, or officers. Better yet, run for one of those positions yourself. But stick with us. Together we can do much good in this world. Cancel that cancellation! ▪