Better Mental Health for Older People





I was aware of the difficulties of establishing new organizations, having founded the American Association for Geriatric Psychiatry (AAGP) in May 1978. I served as president of AAGP from 1978 to 1981 and edited the newsletter from 1978-1986. Beginnings are fraught with struggle and the anxiety that one’s efforts might fail at any moment. A new organization needs infrastructure, funds, personnel, and the profession itself solidly behind it. In the beginning, AAGP had virtually none of these, although there were a dozen prominent geriatric psychiatrists who wished the organization very well. Yet, during its first years, AAGP support broadened and the key necessities evolved slowly but surely. It was in this context that in 1981 I received a letter from Dr. Imre Fejer, a Canadian who had emigrated from Hungary and was working as a geriatrician at Queen Elizabeth Hospital, Toronto. He requested that the AAGP newsletter include information about a new organization in the field of psychogeriatrics that was in the process of forming. As editor, I saw no harm in this and we ran the announcement.

Sometime in late 1981, I received additional communication from Dr. Fejer requesting that I serve on the abstract review committee for a kick-off meeting, the first International Congress on mental health and the elderly, to be held in November 1982 in Cairo, Egypt. The official request to host the meeting in Cairo came from Anwar Sadat, then the Head of the State of Egypt (he was subsequently assassinated, but the man who took his place, Hosni Mubarak, has a brother who is a psychiatrist, and participated in the meeting). I agreed to serve on the review committee, and several months later Dr. Fejer also asked that I deliver the keynote address at the Congress. Of course, I was flattered and immediately accepted. My topic was on the “importance of establishing an international organization in psychogeriatrics,” which also included a methodology to achieve this goal. Despite being excited about going to Egypt for the first time and participating in a landmark event, I really had no idea what was happening behind the scenes. In fact, Dr. Fejer and his colleague Dr. Hans Reichenfeld, from Ottawa, Ontario, were being strongly criticized by some leaders in the field.

Some of my U.S. colleagues then began to fill in the picture. In July of 1980, Tom Arie, Professor of Health Care of the Elderly at Nottingham University, UK, held a two-week course on mental health in old age, the first of several for the British Council. He is one of the most charismatic and knowledgeable psychogeriatricians and a gifted teacher. The course was well attended by psychiatrists, geriatricians, and neurologists from all over the world who found this landmark meeting to be stimulating and productive. One evening, towards the end of the course, Drs. Fejer and Reichenfeld convened a meeting, the purpose of which others thought was to set up a club of alumni so that all who had taken part in the course could keep in touch with one another. Instead it became clear that their intention was to found an international organization. Professor Arie indicated that others had already mooted such an initiative and that this might best be attained through a major existing body such as the World Psychiatric Association’s (WPA) Geriatric Psychiatry Section of which Professor Raymond Levy was then secretary, and Professor Carl Eisdorfer of the USA was chair. It was planned to broach this topic further at the forthcoming International Association of Gerontology meeting in Hamburg, Germany, in August 1981. So those in attendance agreed that the “Nottingham 1980 Club” should be established for course alumni to maintain their friendships and stay in touch.

However, both Fejer and Reichenfeld believed enthusiasm was high and waiting a year meant losing a year. Imre Fejer obtained a grant from the Queen Elizabeth Hospital (Tom McCann, Administrator) and widely circulated a letter to psychiatrists headed “Nottingham 1980 Club – Psychogeriatrics International” styling himself as chair and Dr Reichenfeld as executive secretary. The letter mentioned Tom Arie’s name five times on the first page, giving the impression that he was supportive of the organization. Tom had never agreed to have his name used in this way. Nevertheless, Fejer and Reichenfeld demonstrated enormous energy and commitment into moving IPA forward. They identified hundreds of potential members and sent them certificates of membership.

This led to an escalation of tension in which Imre would call Tom— sometimes multiple times a day—to tell him he was “our pater familias” and needed to be the first president of the organization! Tom had been involved in discussions about the Cairo meeting, but when Imre pushed the matter into a formal organization with some preliminary by-laws, financial support and membership certificates, Tom did not approve. He felt that much more discussion was required so that an orderly structure could be established from the start. Nevertheless, Imre continued his efforts and, with Hans, attempted to push the Cairo meeting into the founding meeting of IPA. Tom decided not to go to Cairo. Some British, Dutch and many others also decided not to attend.

By November 1982, I was much better informed. Nevertheless, I had made a commitment to address an international meeting in a developing country and felt obliged to fulfill that promise. I planned to see Tom in Nottingham on the way from Chicago to Cairo, and while visiting I had the opportunity to watch him teaching medical students, and was very impressed. Fern accompanied me, for we were married in 1982 and after the Congress, took our honeymoon cruising the Nile. We enjoyed a meal with Tom, and he could not have been more charming. It was an emotionally and intellectually wonderful experience. He praised the work of AAGP and thought that an international organization should be based on the same principles and organizational skills. (I didn’t share with him the profound struggle I was having in keeping AAGP going at that time). At the end of our one-day stay there, however, I asked him if I could be of help in Cairo. He indicated his disapproval of the way the Fejer-Reichenfeld organization had been handled and suggested that the more credible vehicle for an international organization would be the WPA. I admired Tom enormously, appreciated what he was accomplishing and what he had accomplished. But, also, he opposed moving forward with an organization in the current structure and leadership. IPA could not count on his support in its further development. I went to Cairo with a heavy heart—and the problems were about to get much worse.

When I arrived in Cairo, I received a telegram from an Israeli, Meinhardt Tropper, a physician who had a paper accepted for this kick-off Congress. Unfortunately, two weeks before the meeting, Lebanese Christians invaded a Palestinian camp and killed many refugees in Israeli-controlled territory. The organizer of the Cairo meeting, Abdel Ashour, was married to a daughter of the last Palestinian mayor of Jaffa in Old Palestine, New Israel. The reaction of the Egyptians to this atrocity was severe, and Dr. Ashour decided to dis-invite the nine Israelis who were planning to attend the meeting. Eight accepted the rejection. Dr.Tropper, on the other hand, wrote telegrams to everyone he knew who was coming, and this had a profound impact on the meeting. At the first business meeting, several attendees confronted Drs. Fejer and Ashour about the dis-invitations and then walked out. This included Herbert Bower, a prominent Australian psychogeriatrician who had agreed to take a Board of Directors seat for this new organization.

In the meantime, Imre knew that the leadership had to change – and fast. The organization was ready to fold at its first meeting, and he was not oblivious to this. He was offering officerships to virtually anyone who would listen, or at least so it seemed. He asked me if I would become president, but I declined. At that time, I had had no international experience in geriatric psychiatry and felt that if the organization had a chance to survive, it needed a prominent internationalist. Yet, with all his efforts, there appeared to be no takers.

Then the neonatal IPA caught a break. There was one geriatric psychiatrist at the meeting who held several prestigious positions—Secretary of the International Association of Gerontology, a member of the World Psychiatric Association Committee on Old Age Psychiatry and the Scientific Advisor for the Sandoz Gerontological Awards. He also had his own large clinic in Cologne and was a professor at a prestigious university in Dusseldorf, Germany. Fortunately for the organization, Manfred Bergener spoke virtually no English then! Thus, while knowledgeable on matters of psychogeriatrics, he had no idea what was transpiring and the potential implications these events may have on his career. I met Manfred the night before his ascendancy to the first IPA presidency under extraordinary circumstances. We were both staying at the Ramses Hilton Hotel in Cairo, the Congress venue. At around 11 p.m., the fire alarms went off, and everyone had to walk down many flights of stairs into the cool Cairo night. At one point, many of us went into the lobby and sat down. It was there that Fern and I met Manfred and his wife, Uta. We were all in our pajamas and bathrobes, and the whole experience was surreal. However, we did try to talk. Uta spoke no English at all, and Manfred’s was choppy and limited. I certainly would not have predicted the impact that we would have on each other’s lives.

When Manfred agreed to accept the presidency, I had a major decision to make. Should I honor Tom Arie’s wishes and resign from the organization or should I stay involved and try to build something for the field? 

My decision was heavily influenced by the fact that 400 participants attended, 300 of whom were Egyptians. As a result of the meeting, Ain-Shams Medical School introduced geriatrics into their curriculum. The Egyptian Medical Association decided to set up a committee on geriatrics. The Rockefeller Foundation decided to set up an exchange program in geriatrics between Egyptians and others in the field. Further, my keynote address was enthusiastically greeted, and I felt a certain collegiality and caring which moved me deeply. The scientific program was excellent with many superb papers from around the world. Several had to do with early biochemical understandings of dementia. Others dealt with geropsychiatric services in different countries, whereas others looked at public policy or education. It was clear that the infrastructure for an organization had been created; thanks to the work of Imre, Hans and Abdel Ashour, and that its impact on a developing country loomed like the Rock of Gibraltar. What would it mean to kill the organization now? How long would it take to recreate a similar infrastructure? Would established leaders in the field take on leadership roles and work to form a new international organization for the field? I thought not. After all, I had waited for almost a decade for that to happen in the United States before I finally took the initiative to set up AAGP. Unfortunately, most of our leaders, accomplished and well meaning, are so busy with so many activities that they often do not have the time to devote to building an organization from nothing.

Removing Political Barriers 

With Manfred Bergener accepting the presidency, there still was one major obstacle related to the dis-invitation of the Israelis. There was much opposition to the establishment of an international organization that refuses to allow participation for political reasons. I addressed this issue in my keynote lecture. I proposed viewing the elderly as a population that transcended political, religious and racial strife: 

“We serve a nation of older people who are united by their age and by the commonality of the psychopathology which can ravage older people and their families. We need to view this group of people, who after all have survived for many decades, from a biopsychosocial framework, and pay attention to the many dimensions of who they are. This includes spiritual and political considerations.

However, these considerations should never interfere with our caring, our learning, and our serving. In the future, we need to travel to countries around the globe without consideration for the political implications. Only in cases of war or severe danger to our member-ship should any country be eliminated from our meetings. They are all united in our eyes as long as they have a population of older people who suffer from mental disorders and/or who have the potential for psychological, social, and spiritual growth in old age.”

The evolving scenario presented a major challenge to the Egyptians. On one hand, there definitely was no fondness towards the Israelis. On the other hand they did not want to see a new organization with its founding meeting in Cairo produce a stillbirth. The solution was ingenious. Ashour called Tropper and invited him to be a member of the Board of Directors. Put aside for the moment that the Board of Directors was more or less handpicked by Imre Fejer. (There had already been a falling out between Fejer and Reichenfeld. Fejer, however, had received the funding from Queen Elizabeth Hospital and therefore had more clout.) At the raucous business meeting during which several people walked out, Ashour placed a call and was fortunate to find Tropper available. Tropper immediately accepted. Ashour came back to the meeting and announced that he was nominating Tropper for the Board of Directors. Hundreds of Egyptians stood in unison to second the nomination, and it passed. Thus, the last significant barrier to my participation in the founding and growth of IPA had been removed. It is ironic that Tropper and Ashour became friendly and there was even an occasion in 1986 at an IPA meeting in Paris where they and their wives sat at a table aboard a boat sailing the Seine and spoke for over an hour with animation and warmth. For me, the IPA journey had just begun, and frankly I was not sure whether it was going somewhere or nowhere!

There was yet one more surreal experience that closed the business meeting. Ashour arose as Bergener was about to ascend to the pulpit and nominated Imre Fejer as the lifetime president of IPA. The Egyptians applauded and so it appeared a done deal. This did cause some confusion in later years. The membership or Board of Directors of IPA never elected Fejer president. Accordingly, he could not be given the title of founding president.

Once the meeting was over, Fern and I went on our honeymoon cruise. Others went on a group tour. We have humorous photographs of Imre dancing with a belly dancer, and the group was in a celebratory mood. There were a lot of Canadians at the meeting, probably reflecting the fact that two Canadians were instrumental in developing the organization.

The Start of Something Big?

Being a musician by background and training, I often have free-associations with melodies going through my head. I remember the tune that was most on my mind at the time was “This Might Be the Start of Something Big.” At other times, however, I thought of the American character in Neville Shute’s novel, On the Beach, who became Commander of the U.S. Navy in Australia, directing a fleet already decimated by war! 

Shortly after I returned to the USA, I received a letter from a doctor in Oregon who had been at the meeting. He wrote that he felt the whole operation was a sham, and that no organization calling itself “interna-tional” should have been involved in such disgraceful behavior. He indicated that certainly he would not stay as a member and encouraged me to resign as well. I kept his letter in a conveniently located place from 1982 to 1997, the year I left the IPA Board of Directors. During IPA’s difficult times, I read it on a regular basis. It served to be inspirational to me. It energized me and enhanced my determination to do what I could to participate in the creation and growth of an organization whose intentions, goals and aspirations demonstrated great positive potential to the elderly and those that care for them, world-wide.

So in 1982, I accepted the position as Secretary-Treasurer, knowing full well that I would catch hell from respected leaders and colleagues back home (this proved exactly right). However, in my heart I felt it was the right decision, and so I moved forward not realizing how this decision would affect my life and how it would impact Fern’s life and career. 

History of IPA, Part Two: December 1982 – February 1984: Much Pain, Little Gain

Sanford I. Finkel has been a Geriatric Psychiatrist for 33 years. For more than three decades he has participated in the growth and evolution of geriatric mental health, and has shaped part of the field by founding the Chicago Society for Life Psychology and Aging, the American Association for Geriatric Psychiatry, the American Psychiatric Association Council on Aging, and the International Psychogeriatric Association. Dr. Finkel is a clinician who continues to see older people and their family members and is involved in innovative research. Current projects include the integration and utilization of a social worker in improving options for older people with depression and cognitive impairment in primary care medical settings, post-traumatic stress disorder in the elderly, and functional, cognitive and behavioral scale development. He is currently Director of the Leonard Schanfield Research Institute and Geriatric Institute of Council for Jewish Elderly, as well as Professor of Clinical Psychiatry, Neurology, and Internal Medicine at Northwestern University Medical School.

Copyright 2014 International Psychogeriatric Association