Paul S. Appelbaum

Paul S. Appelbaum is Dollard Professor of Psychiatry, Medicine, and Law, Columbia University, and Research Scientist, NY State Psychiatric Institute. He trained at Harvard Medical School and Massachusetts Mental Health Center. His special interests include the impact of law and ethics on psychiatry and general medicine, and the ethical, legal and social implications of psychiatric and neurological genetics.

If you were not a psychiatrist, what would you do?

Growing up, I thought I would be an historian, since I was always fascinated by how things got to be the way they are.

What has been the greatest impact of your profession on you personally?

Having had psychodynamic training and seen patients for many years, I think I listen to people differently. Whether I'm talking with a casual acquaintance or reading a judicial opinion (health law and ethics being what I study, of course), I am more likely to perceive subtexts, notice emotions, and look for the drivers of behaviour rather than focus only on the manifest content of what is being said.

Do you feel stigmatised by your profession?

I am proud to be a psychiatrist. I think we work with some of the most challenging patients, and confront the most interesting problems. Had any of my children chosen to go into psychiatry (alas, no physicians in the lot), I would have been thrilled.

What are your interests outside of work?

My wife and I love the theatre, and New York gives us many opportunities to indulge that passion. On the more arcane side, I collect Israeli postal history of the mandatory and early statehood periods.

Who was your most influential trainer, and why?

My first faculty position was with Loren Roth at the University of Pittsburgh, who taught me everything I know about being an academic psychiatrist. He was a meticulous researcher, a generous mentor, scrupulously honest, and had a great sense of humour. Although I have not been able to match him in any of these virtues, he has always been my role model in psychiatry.

What job gave you the most useful training experience?

As third-year residents at the Massachusetts Mental Health Center in Boston, we were on call in the hospital overnights and on weekends, and essentially in charge of the facility. We saw all emergency walk-ins and responded to phone calls from patients seeking help, with just a junior resident in the house as back up, looking after the in-patient wards. There was no better way to develop clinical judgement than evaluating suicidal patients at 3 am.

How has the political environment influenced your work?

Politics shapes the statutory law that I have studied for decades. Criteria for civil commitment, limits of confidentiality, insanity defence rules, restrictions on sex offenders – all of these and more are fashioned in the political process, sometimes in frankly counterproductive ways. Much of my work has focused on examining the consequences of these laws, and suggesting ways that we can do things better.

What part of your work gives you the most satisfaction?

I love to write. My greatest pleasure at work is ploughing through a stack of journal articles, court decisions, and data to synthesise them into a coherent explanation of some aspect of mental health law or ethics. I enjoy figuring out how things work and illustrating that for other people.

What do you least enjoy?

As someone who was chair of a department of psychiatry for almost 14 years, I can tell you that it's a dead heat between two leading contenders for the least enjoyable task: preparing budgets and dealing with personnel issues.

What is the greatest threat facing the profession?

Fear of people with mental illnesses threatens to turn psychiatric institutions into adjuncts of the correctional system. From sexually violent predator laws in the USA to the proposals regarding dangerous severe personality disorders in the UK, we are facing pressure to expand the use of psychiatry for purposes of containment. The danger, of course, is that these new ‘patients’ will take priority over and consume resources better spent on people with more traditionally defined mental disorders.

What is the most important advice you could offer to a new trainee?

There will be many forces seeking to compromise your integrity – both personal and professional – during your career. Protecting that integrity is key to your effectiveness as a psychiatrist, and once lost it is almost impossible to regain.

What are the main ethical problems that psychiatrists will face in the future?

Maintaining the primacy of their patients' interests in the face of competing pressures from government, administration and industry; protecting the confidentiality of the treatment setting in a world in which the zone of privacy is ever shrinking; and avoiding the corruption of psychiatry that will result from succumbing to the demands that we act to contain people who are believed to be dangerous, even if they are not mentally ill.

Do you think psychiatry is brainless or mindless?

We need to mind the brain without neglecting the mind. Even as some leaders in our field lose sight of this essential duality of psychiatry, I am heartened that many of our trainees continue to enter psychiatry precisely because it is the only specialty that offers the opportunity to understand both brain and mind.

What single change to mental health legislation would you like to see?

A statutory requirement that patients be provided with the standard of care treatment that they need would help to drive an infusion of resources into mental health systems, and turn around centuries of neglect.

What single area of psychiatric practice is most in need of development?

Among our most egregious failings is the neglect of substance misuse as a comorbid factor for a large proportion of patients with psychiatric disorders. Trainees should be taught more about treating substance misuse, and especially about integrating treatments for psychiatric and substance use disorders.

What single area of psychiatric research should be given priority?

None. At this point, it isn't at all clear where the major advances in our field will come from. Neuroimaging, genetics, neurodevelopment – they could all turn out to be dead ends in terms of better understanding or treatment of psychiatric disorders. We should maintain a diversified portfolio of research so that we can capitalise on advances wherever they are made.

How would you like to be remembered?

It would be nice if, after I'm gone, someone thought, ‘You know, he did some good work’.