DR. EWALD BUSSE November 28, 1977 EAR Let me just finish the point I was making, I think it is important also to make mention of those instances in which were a variety of reasons things didn't go as well as they might have - where did NIMH miss the boat, where some people were not made some use of, where we didn't get into a :held early enough - there were things obviously where things didn:'' t go as well as they should have, I think I would be terribly• remiss iffI didn't talk to people who also had some criticisms. I can tell you when I see Don Oken tomorrow, I know he is going to make- some connnents that are not going to be fayorable,. but that's terribly important - I don •·t want this to be a prejudiced ·sweetness and light story of NIMH after the fact because obviously, we made a heck of a ·1ot of mistakes and I don't want to miss those and I think in that sense, if I hear you correc;ly, that may be one of the contributions that you make here and I would welcome your frank comments on the way you feel in that regard. I am interes·ted really in individuals how they saw NIMH, what t;hey felt were some of its major contributions from their point of view, what may have been its major deficiencies from their point of view and how the NIMH compares in contrast with other health agencies. I keep on fighting against this I am so invested in the Institute; I have a feeling that circumstances and people at the NIMH that made its unique contribution to what it i_s, but there are ..-1.other agencies that other_ people may have more knowledge of where they saw impqrtant ,o,ther strengths that the NIMH didn tt have, I think we ought to put the NIMH in a lar:ge,r·colltext - it did not exist by itself. Had the NAMH not been around and people like Mike Gorman not being around, the NIMH would have been a differant organization. EB I think I already connnented that I was as close to NIMH as in subsequent years I became involved with the child health and development and even during - 2 - EB(continued) the interim o:f the NIMH I was much more involved with things like the Heart Institute and it was considered at that time the Office of Aging which then became involved with - it is nc;,t the Institute of General Medical Science - it was a division at that time. EAR Right, it was DGMS EB And so that this is where a large focus of my time and energies .went primarily because this·was where the research funding I was interested in came from and it was inevitable that that would be the group I got to know the best. I always had concern that NIMH never was particu,larly:interest;ed in obviously my area of trivia and we were only transiently interested for about two years that they participated in partially funding but then it disappeared again and that came in after it had been approved by the Heart Institute and then they shared funding and then disappeared again and I think this accounts for a large measure why I would not be as close or have the appreciation. of what transpired. EAR But, I wish ydu would say something about DGMS because as you undoubtedly know, when DGMS became NIGMS it was partly a function. of fact that the NIT:s of H saw some holes in the· total supp@:x-t picture that the then NIGMS could take on and was your early invo'lvement with DGMS and call you recall the circumstances that provided their funding ' ' to.yoµ ! ' .. EB Well, my recollection and it·may have some faulty points in it that originally we were predominately involved with the Heart Institute, then for various reaons we were actually transferred to the Office of the Director of NIH - I should know his name immediately - who headed NIH at the same one Bob Felix pulled off. EAR Jim Shannon:> was it not Jim Shannon? EB It was Jim Shannon, sure, and actually for a period of time a.c.tually our research funding came dir.ectly through Jim Shannon t·s office, then it was - 3 .... EB(continued) transferred to TM and Sand a man named Halsey Hunt came into the position there and that really remained for quite a substantial period of time and then- from there it went to NICHD and more recently to the Nationa,l Institute of Aging, so that over these many years of research funding it has been minimally involved •. EAR Isn't that interesting when Jim Behren really began at NIH on the interm.ural program, but I think that ··Bob: :.-Fel'ix' s interest in aging certainly was a strong one - I dont remember when Jim·left. Incidentally, I want to see him when I go to Los Angeles next month, but EB It is at least ten years ago EAR Yes, I am sure it is, but Jim was - actually Jim wrote me a letter and pointed out that he was one of the people who had been with NI'.MH before it became an Institute so he was one of the real old timers in· NIMEr, but I think you are_ right, I think that the ADPO is one that we didn ,:t_ support as vigorously as some of the others. Can you think of any r&asons - I honestly don't know - did they tell you anything? EB No, as two of my relationships with NIMH - when I. was on the Tr~ining Committee I was really on the psychological section:,ef it, I was with the ~sychologis.ts and I was the last psyehiat-pist to be with them. Now I found that a-:rvery stimulating experience because they were what I consider very competent\ behavioral scientists, that proved to be useful to me, but that in its~lf I knew that this was the transitional phase, it had been planned ahead of time. EAR Right, when you left psychologists were just psychologists., EB It came right on _ _ _ _and then there was a gradual reduction in perhaps just two or three,_ but there was a gradual reductio.n of th~ number of psychia­ trists on the Committee, but you can see that for that reason I never even ineerfaced on the psychiatric side particularly, but later I -went on to some Committee that was related to connnunity mental health problems. Now, they did - 4 - EB(continued) have a number of projects come before the. Aging,.:,generally speaking they were unfortunately really designed by relatively inexperie~ced people and it was not therefore, a big positive push to develop psychiatry it was not that well designed. ~..any of them had to be turned down. Now two gentlemen from Chapel Hill was associated with that;. -----in EAR Bill Hollister? EB Right, he I think was the Executive Secretary of that, so he would be very much aware of the deficiencies in the grant applications that came aboard. EAR That's true. That's an interesting point that you make though because there were a num'ber of programs in which early on for a variety of reasons - the quality of the applications that came in were not of the calibre that I think people who wer·e·on the Committee felt altogether comfortable with· ... I remember I came to NIMH in 1958, early in 58, and at that time, pscyopharmaocology program had just about gotten started in 56, and about $3,000,000 to spend in 57. Well, the pump priming in psychopharmacology initially produced a lot of applicationsi;1relatively for quality because the field wasn't ready in those days for a sophisticated project in that field and yet they contin.ued to pump money into it on the presumption that this was going to be an important area and I think ultimately, pscyopharmacology :i.s,:afairly sophisticated field now NIMH did not in of itself, produce that change, but I think it played some role in that kind of pump priming - I don't think the same thing happened in mental health projects that happened in psychopharmacolQgy·pecause it wasn't a substantive area in quite the same way as psychopharmacology was, but your are voicing a kind of misgiving, if not criticism that I think is very valid in these early programs. I was very actively involved when a new se't of training projects came in-· what we called inservice training in hospital improvement projects in the early 60's, and frankly, the early projects in those were horrendous.,.. we had - 5 - EAR(continued) to spoon feed some of those people initially, make sure that one, the application looked like an application and two, that they knew what they were about. -That program is still kind of limping along and I think that,?! wouldit'-¢~; say this with any strong degree of assurance, but I think it made an impact in the general inservice payment of hospital personnel as well as various aspects of hospital improvement activities, so that kind of money depending upon how generous you want to be in your criticism, I think of you as another important a kind of intervention procedure, but getting back to the point you made initially, you were on the training committee where the field and the people on the ?raining Committee were probably as sophisticated as hard-nosed as any of the EB It obviously made me much closer with my feelings with the psychologists than with my colleagues,, which hardly I really interacted with. EAR Is there something retrospective that you could say as a frontier your having been on them biomedically - I know that that dealt with I the total picture, but what were some of your thoughts about the mental health field as a function of having looked at that research program over time in the discussions in the biomedical panel. EB think obviously,. •-its il\c:ill.usion which I I -------------------------- that the research-component had gradually deteriorated over the years - I certainly am not, perhaps you are capable of understanding all of the forces that led to this, but very much believe that this has got to be turned around if we are realJ.:y going to achieve a better understanding of mental illness, so the research component really suffered. EAR Let me ask you an organizational question, be philosophical or not answer if you like. Is there kind of a life cycle to organizations as there are to people so that when something gets to be 25 years old, you have to worry about some \ EAR(continued) kinds of def·iciencies which ta:ke place within an organizational structure - is there something about a new organization if it is fortunate enough to have good people and money and enthusiasm, and a feeling of identity or. is that something you would like to believe tha:t.. isn't necessarily true. EB Well, if you consider a life cycle with a beginning and an end - I don't believe this, but I think it is very evident that any organization that has appeared through time undergoes many changes and periodically they must be earefully evaluated and redirections assumed. - sometimes they float mnto directions without clear planning or forward planning, which is most unfortunate. I got the impression that many of the decisions at NIMH, not decisions, p.ositions that they were forced into were politically generated rather than with any scientific basis. Therefore, they were expedient for the politician ·but negative for the·behavioral science and this is very unfortunate but this transpired, you have heard this many times. EAR I think it is a point well taken and I think that it was perhaps best epitomized in the interplay between the members of the<Advi:sory Council and people like Felix and/or Stan Yolles when he took over.. I have a long letter from Eli . Ginsberg, who had been on one of the NIMH Councils' and.you know if you ask Eli Ginsberg a question, he writes a book, so that, I 1 got literally a 30 page reply from him, which was very insightful - I think critical of Niffll from a standpoint of how he as a Council member tried to keep the Institute's fire so to speak, about old planning, about trying to be accountable to know what you are d.oing, trying to recognize if it would.take~ turn this way or that way, the consequences that yon have to accept, he was and:.;.re111a:i:ned critical of expenditure of monies for things that he thought were not really on a cost accounting basis worth spending. At the same time he is enough of a realist to recognize tha.t some of those things in a political atmosphere were almost inevitable, but I think the story needs to tell both those sides, that there are inevitably organizational EAR(continued) and programmatic deficiencies which arise if you pay too much attention, if you are too expedient, or if you pay too much attention to the political pressures· - how one strikes a happy balance is another question and I think you are abso·:tutely right, that is what took place - I don't know if anybody has the wisdom after the fact to be able to say how you might have done it better and especially not during the time that you are involved in these decisions with all of these multiple forces -i1npinging upon you simultaneously - it would be very very difficult. Were there any parttcl'.llar incidents in youvsomewhat closer affiliation with NICHD that would serve as useful contrasts between that institute for example and·NIMH? EB Well, I would assume and I think you pointed out in our general conversation that the beginning was so different that they were charged with the responsibility of developing 18 year search and so on.their Council and they did have a section for it - they had their own study section ... and a number of us were always on the Council to represent an interest in a lot of the research _____-...-_......._._that relates to Jerry ~ there was a lot of the methodolgy that was used in child research; so it wasnr;t: very difficult for us to develop good communications and understanding and is so common a lot of us who were on geriatrics actually came out of child research so it was a relatively comfortable situation. EAR What was your feeling about your role on the child health Council and your relatinnship to staff - were they as you saw it responsive, did they use the Advisory Council effectively - did your recommendations get put into programmatic changes, etc. 0 - 8 - .EB The Director and I know we are going to avoid if possible names, followed the original Director EAR Jerry Leveck? EB Yes, Jerry Leveck was very resistant to listening to Council he had his own agenda. Now this not only applied to geriatrics hut to many child adolescent research and. it required a number of times for the Council to confront him and insist that he be more responsive to their own ideas and keep his eye on the ball so to speak and those were some very interesting confronta­ tions - that's what they amounted to. EAR What role, if any, did Joe Bobbitt play - was he there at the time? EB Joe was there as I recall as a liaison person for a period of time. EAR Then he became Assistant Director EB So he was there in 'two roles - now Joe, of course, was an old hand and very sensitive how you use a Council effectively. I think many times he was caught in middle. EAR One of my great regrets is that I didn't get a chance to spend time with Joe because as you know he was Bob Felix's right hand man at NIMH early on and I had know Joe very well at NIMH - we were very close friends, he was a delightful man, and t3wards the end unfortunately his experiences in general were not too happy and so I just missed, I had made.an appointment to see him and he died, just about the time I was going to come down EB NICHD, I know that's not what we are talking about in part suffered from an inadequately trained staff it was not only the _ _ _ program that was deficient but there were other areas - 9 - EB (continued) that were efl.:eai,1-;ynot as strong while there were others which were remarkably good and so they would get preference if we took the leadership role and knew the area of science and knew it well, you could see the strength emerging and a number of times the Council got very concerned with t}:le weakness of certain staff members - up at NIMH, too. EAR That's true and as a matter of fact you remind me now - the Commander _____Halsey at DGMS who took his place as the Director EB It might have been Duncan EAR No, I have forgotten but anyway·- i t is a short name EB You don 1 t mean the guy who is still around the Heart I'nstitute? I can see him very clearly because I run into him.periodically EAR Well, it will come to us but anyway the point that you made about strong staff as you know early on NIGMS had the responsibility given to it by Jim Shannon the beginning into the behavioral sciences field and we at NIMH were somewhat competitive about other people getting in to what we saw as our territory and I was then Assistant ------ EB Damnnear, but go ahead EAR And I kept on telling him really I mean' t well, I. said ,t,look, before you decide how you are going to program, what you are going to program, how much money, get the best possible behavioral scientists in on your staff and give them their head and I think you will then run a good program. I can tell you that the secret over here in psychology for one, for example; both on the research side and on the training side, we have very competent people, they know what they are doing, they have program interests, they have program identification and they are strong people, you do that and - 10 - EAR(continued) we will be happy to cooperate with you because it will, be that much more money in the field of behavioral sciences and that's the thing we identify with and they found it very difficult to do that, maybe they couldn't find anyone, so I think that your reflecting very clearly how it is that competent people manage to get their programs more visible. Well, how - were there any particular - I am interested iil the point about how the Child Health Council responded especially about Jerry Leveckts role, not us~~g him as a name, but just in terms of the Director of the Institute, perhaps not making the most effective use of its Conncil members, were there any particular incidents in which that confrontation really illustrates how the Council tried very hard to get this point of view across to the Institute. EB Oh yes, they were. EAR Could you describe one for me? It would be helpful EB What I am stuck with is that I don't remember, of course, the Aging one I am familiar with, there was one that really concerned Elizabeth Boggs in mental retardation, but it wasn''t directly related to her in particular but she really identified clearly the serious defects to the child problem. There were a number of complications and the same thing transpired over in Geriatrics, with very little new things. EAR Now, whem you came back for the next Council meeting, did you ask for an accounting from the staff as to what had happened, how were the confrontations actually brought to a head, so to speak? EB Usually, unfortunately, it had to be brought to a head by us having a meeting hy ourselves without staff and without Gary present in EB(continued) order then to demand.that we have a session the next day EAR You add to your own executive staff EB Usually at the hotel and that was most unfortunate and then when we did have them, every effort was made to then clutter up the agenda so much that we couldn't get really into the substance,:~of our own problems, it was always manipulated. EAR This is a very important story because I was on the other side,, on the staff at NIMH and I can tell you that we had some very strong people on our Council as you well know, Jack Ewald, Ell Ginsberg,· Frank Braceland, who was strong but in a very gentle sort of way, John Whitehorn and people that you know and Mike Gorman, for example, who piayed an unique role because ef his style aQd his natural ability in his political contact and Bob Felix had a remarkable way of handling these things which was almost inimatably Bob Felix, when something came up and the Council in a sense really started to fight about something and he didn't want this to happen, he would back off and say with a kind of smile on his· face, "now this is exactly what I want,. you pepple are now earning your keep, so to speak by really talking important sub­ stantive issues and then aft~r the meeting if he felt that it was something that the NIMH should do, he would do it, and if he thought it was something NIMH -should not do, he wouldn."t do it, but he literally catered to the Council and I don•t mean· this in a totally manipulative kind of way because he was sincere in his own way, as sincere as any of us could be sometimes without recognizing your own motivati-OD<'-<~, - 12 - EB Why was· this, my thoughts jump, it is still apparent that there was ve~y uncomfortable relationship between Shannon and Felix, it is still in Jim Shannon's mind, I can tell you, I have seen him periodically and he brings it back up. EAR Well, I can tell you the answer to that, I think part of it is clearly personalities, Jim Shannon is a very strong man and Felix was a very strong man and they had dif.ferent points of view and Shannon felt that NIMH should be a part of NIH and there were things that we did at NIMH, including the whole service program, which no other Institute did, the clinical training programs which no other Institute's did and Bob probably had a closer tie, a closer personal tie, with the people on the Hill and there was Jim Shannon on the one hand trying to do something at the NTH level and there was Bob Felix making an end run. Now, the climax to all this in one sense, was when they tried to split NIMH up in the late 19SO•s and early 196Qts~ and one part of NIMH was going to remain at NIH, namely the research and the service was going to go downtown to the HEW and that is a story unto:'itseif which is a very important story about how Bob Felix with political help managed to deter this split up of NIMH. In. the meantime NIMH was growing faster than the Heart Institute was growing, growing as fast almost as the Cancer Institute, and Jim Shannon, of course, came from the Heart Institue initially, that was his affiliation and I think it was two strong-minded people clashing, two people with very clear differences of opinion as to the way all of NIH should go and Shannon's strong conviction that NIMH - 13 - EAR(continued) should be subordinate to NIH and Bob Felix was equally as strong with his conviction that NIMH was an Institute unto itself, which should have rules that it played by which did not necessarily have to be the same tules that NIH played by and I think Shannon was annoyed with BoB, I think he was even more angry with Stap Yolles because Stan were him, Stan was an upstart, at least he could look at Felix as an equali but here was this young character coming along as hard as brass and as independent and kind of unregenerate as anyone could be and running the show, I think Jim Shannon never really had a happy or warm feeling about NIMH. I would like to . talk to him if he was willing to talk to me ---,, ........-.---·•-·--~---.,"'•-.:.-. because he obviously did play an important role with the NIMH. His story should be told, he was an incredible man.· I think that NIH owes a great deal of its growth and development to Jim Shannon~s political and sciebtific and professional EB Very determined EAR Did you have many interactions with him? EB Yes, I did, there was always a little bit of a hostile edge to our relationship becasue he really wasn't comfortable with psychiatrists and he still isn't~ We still have interaction because he is on the board at the Whitehead Institute which I relate to and through. He is still -:cino·t~H!,ver ~it:i~-:,~bu:t':f'he has always when the chips are down been helpful EAR He is an honest man and I think that determines his ultimate decisions and I think that is very important. I have had some - 14·- EAR(continued} interactions with him even though I was in a much lower echelon. I was very impressed with him. He is a hard man to hear, his voice was always so low and I used to attend what we call the Assistant Direc~:Or's Extra Mural programs and if you werenl'.t sitting in the front of the room, you some times had difficulty hearing him. Well, I know your time is very limited and I don't want to quit before I give you a chance to, in terms of what we have done, we have rambled over, I know we have, but is there anything else that comes to mind EB There is one concern I have, not that I have the answer, at least in a·· university setting, I think it is quite possible to maintain service commitments, research commitments in education, therefore, I have wondered why it got out of proportion in the NIMH' and I wonder if it really isn't referred to earlier the fact that the political people could tell NIMH that had to develop a commitment and often without the funding to do it, so that they had to shift their energies and funding to ---sort of mandate from Congress and otherwise I can't believe that there isn"t considerable vitality to maintaining the research component allied with the service ones, so it must not be the basic concept in the scientific value, it must be again when you have external forces that interfere with the· administrative. EAR You are asking a very difficult question, let me try to answer it by telling you what I use to use as an argument. I was before I moved up to the AssistAnt Director for all extramural programs, I -- 15 - EAR (continued) actually was in charge of the entire Training Pro1gram, I was the Assistant Director for Training and as a psychologist I was then in charge of psychiatry programs, well, fortunately, most of the psychiatrists on the staff were reasonably comfortable with a psychologist being in charge of the pro~ram because they had thought that I had sold psychology that psychiatry was getting the bulk of the money and they didn't think that was appropriate since they ran a much better show and psychology was in their right much more strongly the research comppnent or the entire mental health field, etc., very justifiable. But, I think what they ignored was that, and,this is my personal point of view, I think that the total NIMH research and training program, well I will get back to the service program in a minute, I think the entire research and training program, all four components, psychology, psychiatry, social work and nursing were benefitted by the fact that psychiatry was the most visibi'e,· that the people in the political arena saw this as a medical program and were less concerned with putting money into these other fields but were tolerant of it and accepting of it as long as they continued to see the visibility of the medical component and. so every time additional funds we,re put into psychiatry whether it was something like the general practi.tioner program which Mil(e.;;}'Gorm.an really initiated. EB I remember.that EAR Whether it was something like that or regular psychiatry prog:i:-ams, remember I am not talking about the present times, I am talking about earl'~rer-iron, they were equally right to put a little bit extra into the pot for the/•o.ther three fields and my argument was - 16 - EAR(continued) the expedient argument was, if it weren't this way I don't think psychology,, social work and nursing would have gotten that additional funding, so it is not that psychiatry is getting that much more, i t is that in a sense, you would be carried along because the political reality is that the people in Congress see this as a medical program and you are not about to change their mind on that. Now, I think part of that same phenomonen is true ~lh',the .community mental heal th program and the increased service program came in, I don ''t think and it will be hard to test my thesis for that, I dontt think it wasat the expense of research and training, it's just that the community and service programs grew that much more rapidly, it isn't as if there wa:s a finite amount of money and some of it was taken out of research and training and put into community services. T think additional funding came along, more of that additional funding went into the service programs, but the research and training programs grew likewise and if you look at graphs through the mid 60's anyway when I left, research and training continued to grow, it,, s true that the community mental health program took off at that time •. EB Now they have declined EAR Right, now I think that's why I want to quit at 1971 because it is a different ballgame and I ca~'t explain that, I donlt know all the dynamics as well as I did before, but I was very intimately involved when the community mental health program was in develop­ ment, I was the manpower expert, I literally had to go testify before the Bureau of the Budget·as to why we believed we were - 17 - EAR(continued) going to be able to produce enough psychiatrists at the expense of other medical specialities and why that was important to do, so that literally, as I am sure you are well aware, the decision was made at the last moment in the White HOuse that the community mental health centers legislation would be supported with official funding with all the psychiatric training with the clear foreknowledge that this might cut into the number of specialists that went into all the other medical specialties, since the. total output,t•from medical schools was held was finite and as you know, psychi~try went up from about 7% to 11 or 12%, now it is declin;ng back down again, but that was done with foreknowledge and I think at the same time psychology, social work and nursing also got a good bit of funds, but you are right, since 1970 and on Well, EB Well, I am going to have to quit EAR Listen, I certainly do _appreciate your taking the time very much