Peter Ash, MD: Evolution of a Forensic Child Psychiatrist
=========================================================

* Stephen B. Billick

The true task of a biographer is not just to record the facts and details of a life, but to do so in such a manner that something of that person's essence is revealed. The life of Peter Ash, MD, the 37th President of the American Academy of Psychiatry and the Law, is full of complexity, depth, and detail, but if the words in the pages that follow are true of him, what will be apparent is his singularity, the very distinctive and particular stamp he has put on life.Although as psychiatrists we are schooled in interviewing and making complicated analyses, in some significant sense, the story of our lives, for one who knows how to look, can be read in our faces. The look in our eyes is like a unique fingerprint, our calling card to the world. So what does Ash's face reveal at 63 years of age? His wife, who knows his face well, sees his inquisitive nature, his piercing intelligence, his pleasure in irony and wit, his integrity, responsibility, and lack of pretense or guile. Although all who meet him can’t help but be struck by his fine intelligence and breadth of knowledge, his wife notes that a close second glance will easily reveal his compassion, generous heart, and wish to be of service. As a teenager, he noticed that if all the double seats on a bus had one person and another person entered, that person would invariably sit next to him. He interpreted it to signify that he must have seemed harmless to others. His wife, who has taken that seat next to him for years, says it is because he has that something special: a warm empathy and a good heart. I am in total agreement. I have known him for decades, and he is one of the nicest human beings I have ever encountered. He is a truly good person who loves to do things for others to make their lives better, happier, and more productive.

As I gathered the specifics of Ash's life, I was struck by the dizzying cornucopia of interests he holds, encompassing mathematics, computer science, psychiatry, law, travel, outdoor adventure, child rearing, gardening, musicianship, yoga, and meditation. At times he has labeled himself a dilettante for his jumping from one interest to another. But the truth is he is far from dilettantish. He has the Renaissance man's mind and soul. In addition to this quest for knowledge, Ash's life has been one of substance and devotion. He is devoted to his family, his profession, and whatever retains some element of mystery, something yet to be known, something yet to be experienced. It is clear that interests retain their element of charm for him as long as they contain mystery and its inherent challenge. When the challenge is gone, he will move on to the next adventure.

Ash was born in State College, Pennsylvania, which at that time was a bucolic small town, and Pennsylvania State University was a much smaller university than it is now. It was a great place to be a small child, with the Nittany Lion statue to climb upon and all the animals to visit at the “Ag School” where his grandfather taught agricultural engineering. Ash's parents had met and married during World War II, and after the war they moved to State College so that his mother could be near her parents while his father attended graduate school in industrial psychology. His mother devoted much of her energy to raising Ash and his younger sister Sherry. In her later years, she became a certified public accountant and then an attorney. Ash's love of new learning did not develop in a vacuum.

Ash was a good-natured, likable child who excelled at school. The truism that a child's mind is like a sponge was particularly true of Ash as he soaked in vast amounts of history, math, and science. In later years, one of his daughter's friends likened him to Dumbledore of *Harry Potter* fame because of his encyclopedic mind. To this day he often surprises the family at the dinner table with his retention of obscure facts learned in childhood. Oddly enough, he was the shortest one in his class all the way until college, when he suddenly shot up to his current six foot stature.

Ash's father had wanted to be a psychiatrist, but growing up in New York during the Depression with very little money, he knew that medical school was out of the question. While a college undergraduate in the 1930s, his father had worked at the Psychiatric Clinic of the Court of General Sessions, commonly known as the Tombs. He sat in on the psychiatric examinations of prisoners conducted jointly by three psychiatrists and started recording the diagnoses each reached on the basis of the same interview. The data, presaging the need for the Diagnostic and Statistical Manual, showed very poor diagnostic agreement among the psychiatrists. In fact, the agreement was so poor that the chief psychiatrist who headed the clinic forbade its publication for more than 10 years. When the paper was finally published in 1949,1 it was one of the first studies to demonstrate the lack of reliability of psychiatric diagnosis. Ash's father's iconoclastic spirit impressed Ash in two important ways. One, it's better to be the one wielding power than the one power is exercised upon. It was clearly more auspicious to be the psychiatrist than the psychologist. Two, don’t take the power all that seriously, because it isn’t always based on the most legitimate foundation.

Ash was instrumental in bringing computer knowledge to the American Academy of Psychiatry and the Law (AAPL). He founded the Computer Committee, created the first AAPL website, and was the website editor for AAPL for over 10 years. How did this psychiatrist attain such competency in computers? His interest and unusual aptitude in computers goes way back. In the late 1950s, when he was in seventh grade, he met an electrical engineer who was into gadgets and tools. The engineer had a machine shop in his basement, including a large milling machine and band saw. He also had persuaded several electronics companies to donate surplus parts, and invited Ash and several friends to make use of his basement to build a computer. One day, as Ash was soldering a multiplication board in the basement, the owner came down the stairs with some Russian scientists who were touring the United States. At that time, the Cold War was going strong, Khrushchev had recently been denied a visit to Disneyland, and few Russians had been to the United States. The Russians’ eyes popped out as they stared at the boxes of transistors and diodes surrounding several school children building a computer, as the owner said airily, “Oh, this is just a typical American basement.” After his junior year in high school, Ash spent a summer with his uncle, who was then director of the computer center at the University of Miami. That his uncle had a 29-foot sailboat and was happy to take a few days off from time to time to sail over to the Bahamas for some skin diving was an added incentive for the visit. At the computer center, Ash had access to a new IBM 1401 computer with a large (for then) 8K memory that took up most of a room with its CPU, punch card entry unit, and printer. Ash taught himself programing, and over the next few years parlayed his computer knowledge into a succession of summer computer jobs with IBM, AT&T, and Sears. Programing remained an entertaining hobby, and when the web came along, he was happy to code the first AAPL website.

Throughout his later childhood, Ash had thought he would be a mathematician. It was fun, and he was particularly good at it. After about six months at Harvard College, having met some real world-class math whizzes, he decided he wasn’t that good at it after all. He wanted a field where he could make a mark and was unsure what he should do. Over the next few months, he changed majors so many times that the staff in the Harvard office gave him a stack of change-major forms so he wouldn’t have to keep coming by to pick one up. One day, looking through a student-written guide to courses, he read the comment that “Philosophy teaches you how to think.” That, he thought, would be useful. He switched to philosophy and social relations, which he happily studied for the next three years. His roommate, Dan Hausman, was a biochemistry major determined to go to medical school, and they discussed careers during the years that they roomed together. Ash is now a physician. Hausman is the chairman of philosophy at the University of Wisconsin, just the sort of ironic twist in life that Ash finds delightful.

The switch to medicine came abruptly. Sitting in the back of his epistemology class one day near the end of junior year, Ash started thinking about what he would do with his life. Philosophy was fun, but he never intended to be a professional philosopher. He thought about various possibilities in the social sciences—he had a social relations minor—and had been considering psychology as a career. His father was successful as an industrial psychologist and his uncle a clinical psychologist, and he recalled many dinner conversations about how psychiatrists had so much influence. He didn’t want to spend his life, too, complaining about psychiatrists. He decided to be one instead. He walked out of the class, called his parents, and told them he was going to medical school. Introductory chemistry in summer school, an unusually heavy load of science courses for a senior majoring in philosophy, and he was off to the University of Pennsylvania School of Medicine.

Ash went to Penn intent on becoming a psychiatrist. After a few months of studying anatomy and pathology as a first year medical student, he went to his advisor, the anesthesiologist Harry Wollman, to tell him that he really wanted to try psychiatry, because if he didn’t like it, there was no reason for him to stay in medical school. Penn allowed considerable elective time, usually taken in the third and fourth years. This was university education in the late 60s and early 70s. His advisor suggested that he spend some of his second trimester in the first year doing an elective in outpatient psychiatry. “But I haven’t had physiology [a required prerequisite for clinical courses],” Ash said. “Psychiatrists don’t need physiology,” Dr. Wollman replied. So Ash went to Dr. Philip Mechanick, then the head of the psychiatry outpatient clinic, and asked if he could do an outpatient elective. “But you haven’t had physiology,” said Dr. Mechanick. “Psychiatrists don’t need physiology,” Ash replied. Dr. Mechanick looked pensive for a moment and then said, “That's true.” Clearly, these events took place before psychiatry had become so deeply wedded to psychopharmacology. In the clinic, Ash had his own patients, lined up faculty supervisors, skipped other classes to take on more patients, successfully begged for extra supervision from senior psychiatry residents, and realized he’d found what he loved to do. Penn had an outstanding psychiatry faculty: over the next three years he took clinical rotations with Joe DiGiacomo (inpatient), Karl Rickels (psychopharmacology research), Salvador Minuchin (family therapy), Harold Lief (marital therapy), and Martin Orne (hypnosis), and had a two-month stint at St. Bartholomew's Hospital in London, where he also went to the theater at least twice a week. He never did take the required clinical rotation in psychiatry, but he did take physiology. He also developed an abiding view that people learn best when they have considerable freedom to pursue what they want to learn, a view that was to strongly influence the structure of the forensic psychiatry fellowship he later developed at Emory.

At the time Ash finished medical school, the ABPN (American Board of Psychiatry and Neurology) was conducting an experiment that allowed those interested in psychiatry to skip an internship and go directly into what would now be considered PGY-2, shaving one year off the total training time. (After two years, the ABPN reverted to the previous timetable, and PGY-1 changed from an internship to an integrated psychiatry/medical experience, to be followed by three more years devoted to psychiatry.) Most of his friends who went into psychiatry elected the shorter route. Ash, although dedicated to a career in psychiatry, didn’t really feel like a doctor, and, having invested four years in medical school, he wanted that identity. He applied for rotating internships, which allowed interns to take much of the responsibility for patient care but didn’t look too taxing. Presbyterian Hospital in San Francisco seemed attractive, call was a relatively leisurely every third to fourth night, the interns were happy, and during his interview he noted that construction of a modern, larger hospital was almost completed. He got more doctoring than he bargained for. The expanded hospital was wildly successful, the patient load doubled, and the interns’ workload doubled with it. He learned how exhausted one could be and still function.

But Ash thinks that the major lesson learned in his internship was how psychologically to deal with death. For the first time, people who were in his care died. Early in his internship, he was awakened one night by a call to come and pronounce someone. In his sleepy state, he asked, “Pronounce? Pronounce? What do you want me to say?” “The patient died. We need a death certificate completed.” When he went to examine the patient, he wondered, “How can I be *sure* he's dead? They never taught me that.” He couldn’t see any breathing, couldn’t hear a heartbeat: “Wait, was that sound a heart beat or my bumping the stethoscope?” He remembered a detective story where the detective pressed and then released the victim's thumbnail, and it stayed white, so he tried that. But the thumb turned a little pink. Finally, thinking, “The nurse wouldn’t have called me if the patient wasn’t dead,” he signed the death certificate and went back to bed. And he had a dream. In the dream, during rounds the next day, when asked whether there were any changes in Mr. X, Ash reported the patient had died. Then the group walked into the room, and there was Mr. X, sitting up in bed eating breakfast. Ash awoke with a shock, thinking, “How will I ever explain that?” Coming to terms with the fact that sometimes one's patient dies was crucial preparation for his later work with highly suicidal patients and for consulting on suicidal and dangerous patients in high-stakes situations.

Ash chose his psychiatry residency at the University of Michigan, in part because at that time, the Michigan adult residency included a full year of work with children, which he thought would be useful in understanding adults. When he found he very much enjoyed the work, he added one more year to complete a child fellowship. During his residency, his cousin, who ran a small vocational rehabilitation business in Detroit, asked if Ash was interested in conducting psychiatric consultations on some of the rehabilitation clients. His cousin advised him, “Just call it as you see it,” and he felt no pressure to find one way or the other. It was a great Saturday morning moonlighting job. Since many of the clients were involved in workers’ compensation or third-party injury litigation, he was deposed on his findings in some of the cases. After he finished his child psychiatry residency, he became a medical advisor to the administrative law judges in the Detroit office of the Bureau of Hearings and Appeals who heard appeals in Social Security disability cases. Before his first appearance, his cousin told him, “There's nothing to worry about. Those cases are informal. The administrative law judge will ask you some questions about what's in the medical record [medical advisors do not interview the claimants] and what it means, and whether the impairments meet the criteria of the *Listings of Impairments*. Then the claimant's attorney may ask you a few questions. You might testify for about 15 minutes, max. The whole hearing is scheduled for an hour.” The claimant's file indicated back pain with no objective findings, and so disability was claimed for resulting depression that by itself caused few if any vocational impairments. The cross-examination went on for over three hours, with the attorney shouting most of the questions. “Doctor (waving a large book in the air), have you read this book?” “No.” “What?! How can you practice psychiatry without having read this book?” And so on. Flooding is a good treatment for anxiety. No other cross-examination in Ash's experience ever came close to the sustained decibel level of that first one. He also found that he liked the challenge of maintaining grace under pressure.

After residency, Ash joined the faculty at the University of Michigan in the child psychiatry division. About a year later, Mel Guyer, an attorney and social psychologist, started the Family and Law Program, and Ash began working on the program a few months later. The program specialized in child custody evaluations and also began receiving referrals of cases complicated by sexual abuse allegations. Those were exciting days in child forensic psychiatry. In the early 1980s, the slogan “children never lie” still had currency with many sexual abuse evaluators, who saw no problem in utilizing suggestive or even coercive interrogation techniques when interviewing children. The Family and Law Program received many referrals for second opinions in cases in which there was concern that one parent's allegations of abuse might be false. Contested custody evaluations and, somewhat later, nursery school molestation cases in which satanic ritual abuse was alleged, epitomized by the McMartin case in the late 1980s, sparked widespread interest and research into the effects on children of suggestive questioning. This work led to a reformulation of what constitutes appropriate technique in the forensic evaluation of a child. Ash found child forensic psychiatry to be an exciting and intellectually challenging field, and he liked thinking through the tough decisions that custody evaluators are called on to make.

The Family and Law program tapped a latent need in Michigan, and the program began receiving enough referrals to create a large sample of contested custody cases that provided data for a range of research efforts and publications. The program received so many referrals of other types of child forensic cases that, in the mid-1980s, the service began a fellowship specifically in child and adolescent forensic psychiatry, at that time the only such training program in the United States.

Although Ash was also director of the outpatient child psychiatry program, by the early 1980s much of his work was in child custody disputes and adult work-related disability claims. He started thinking of himself as a forensic psychiatrist. When he wondered why he had ended up in that sort of work, he recalled that back when he was about 11 and wondering what he would do as a career, his father had given him the Strong Vocational Preference Inventory, a then-common test that purported to assess what occupations were suited to the test-taker's personality. The results were unambiguous: Ash should be a lawyer. As a child, and indeed through college, he never seriously considered law school. The idea of having to argue for whatever side happened to hire him was never appealing. But there he was, in his early 30s, doing a great deal of forensic work, enjoying being able to perform unbiased evaluations. He liked thinking through complex cases and then advocating strongly for his opinions. Having recognized that he had become a forensic psychiatrist, he did what any sensible forensic psychiatrist would do: he joined AAPL.

There, he found a collegial and intellectual home, a place to meet with like-minded colleagues and share ideas. AAPL was also broadening: Ash's work had been almost completely in civil work, and at AAPL meetings he learned about the full array of forensic cases.

At a holiday party in 1983, Ash met Meg Jaffe, a psychologist who became the love of his life. They married and soon had a family with the births of David and Marcia. His family became the emotional center of his life and raising children one of his greatest joys. It was educational for him to learn how incomplete developmental theories were. Back then, child psychiatrists were taught that children aren’t cognitively capable of anticipation of events until about eight to nine months. Ash then asked himself, “So how could David start to cry when he saw his mother dressed in work clothes shortly after she returned to work part-time when he was only three months old?” Ash and Meg were warm and empathic parents, and their children later said they had never felt “analyzed.” Ash and his wife took it as a great compliment when a second-grade teacher at a parent-teacher conference pronounced them the most normal parents involved in mental health that she had met. But it did come as a surprise to those psychodynamically trained parents to find that if you really wanted rapid change, go behaviorist. Toddler Marcia wouldn’t consider giving up her pacifier in response to months of empathic comments or appeals to wishes for developmental mastery to be like “the big girls.” She was, however, happy to hand it over to a Toys ‘R’ Us cashier to buy an armful of Barbie dolls and their outfits.

In 1993, Ash left Michigan to direct the Psychiatry and Law Service at Emory University in Atlanta. He likes to tell people that at Michigan, he was a child psychiatrist with an interest in forensics; at Emory, he became a forensic psychiatrist with an interest in children and adolescents. When he arrived, he started the forensic psychiatry fellowship at Emory. In the early 90s, the Emory program was one of the few that offered considerable experience in child forensic work, and so attracted many child psychiatrists who were seeking forensic training.

I had the opportunity to do the ACGME (Accreditation Council for Graduate Medical Education) site visit for Ash's forensic fellowship accreditation at Emory in 1996. I was of course impressed with Ash's excellent organization and his meticulous attention to detail, but the warmth of his residents toward their director was simply astounding. Ash clearly relished guiding his fellows into the exciting field of forensic psychiatry. He also spent considerable time teaching the general psychiatry residents. He loves being an educator, and he is truly gifted at it. During the site visit, he told me that his chair had authorized him to take me to a wonderful restaurant in Atlanta. Since New York City is brimming with fine restaurants, I asked to go to a simply delectable southern BBQ restaurant where the total tab for both of us was $15. I told Ash that I had saved the Department of Psychiatry some serious cash. Ash laughed and with his usual meticulous precision, responded that his chair had authorized him to take me to an expensive restaurant but he had not authorized departmental reimbursement. Ash was the one who was expected to pay. His initial invitation to me for lunch had been typically Ash-precise. This site visit helped me to see the integrated, complicated, and complex aspects of Ash's personality. He has a phenomenal breadth of knowledge, a thirst to learn more, incredible warm human empathy, and that astounding desire to be meticulously accurate.

Because of his work in custody disputes, he was appointed by the Georgia Supreme Court to the Georgia Commission on Dispute Resolution. The commission sets policy for alternative dispute resolution procedures in the Georgia courts and was made up primarily of judges and attorneys. Ash's excellent administrative skills were recognized, and he was later appointed chairperson of the Commission. One of the Commission's functions was to hear appeals on ethics and mediator qualifications. While Ash has chaired many meetings, he once said the most anxiety-provoking was being a psychiatrist chairing a quasi-judicial hearing when the hearing panel included a state supreme court justice, a court of appeals judge, and about five other judges.

Atlanta had a much greater delinquency problem than peaceable Ann Arbor, and Ash quickly became interested in the causes of delinquency. He was intrigued by how people who are violent think about what they do. He became interested in why some adolescents carry guns and began a research project that included sending forensic and child psychiatry fellows to interview incarcerated delinquents about their handgun use. The fellows were shocked at some of the stories they were told. The data gathered became the basis for a research paper published in *JAMA*.2

When Ash turned 50, he took up yoga, in part with the idea that it would retard his body's turning old and creaky. He quickly became a daily practitioner and soon added meditation to his practice. When AAPL meets at a beach location, he can usually be found doing yoga poses by the waves as the sun comes up. His meditative practice laid the groundwork for a transformative shift several years later. He experienced symptoms that suggested unstable angina and was admitted to the hospital for stabilization, angiography, and possible surgery. As he wrote later3: After waiting a harrowing night, the cath was normal. There is wonderful relief in lying there looking at the X-rays of blood pulsing through your open coronaries. I had six months of rebound euphoria. Life is great! All those worries about things I had to do in the next three days? Hey—if it won’t kill me or my family, I am NOT worried. Life has been much more enjoyable ever since. Some of the euphoria has worn off with time, but my perspective has shifted decisively. I’ve learned to enjoy an experience not just for itself, but also to appreciate it as an instance of being alive. Even pain is interesting if you appreciate being conscious to feel it.

His sustained interest in yoga and meditation is an instance of his deep desire to push the frontier of what he can know and experience. Growing up in a family that highly valued the mind and intellect and took great delight in their son's intelligence, it is no small feat to enter a practice (yoga and meditation) whose entire goal is to experience presence while holding the mind in abeyance. He is now faced with the task of figuring out how, with such an active probing mind, one sets the mind aside. What kinds of experiences does one have in doing that and what is their value? I won’t try to give Ash's answer to those questions because they currently hold mystery for him and hence challenge and charm.

Yoga and meditation, however, are not Ash's sole nonintellectual pursuits. He has a long-standing love of the natural world and delights in travel to foreign lands, visits to National Parks, and beautifying his own creek-lined backyard, imagining bright yellow lilies blossoming against the backdrop of deep blue hydrangeas, and then making it so. His yard is lush with camellias, azaleas, wandering paths, stack stone walls, and sculpture peeping out among flowering bushes. One of the gifts of moving to Atlanta from Ann Arbor was the great boon of having year-round flowering plants.

Another keen lifelong interest has been Ash's love of music. In his teen years he played the oboe and took lessons in downtown Chicago with Ray Still, then first oboist in the Chicago Symphony. Ash also plays the piano. He teasingly insisted that his middle age would be his cello years. When his wife and children took him at his word and bought him a cello for Father's Day when he was in his late 50s, he felt a mixture of astonishment and delight. “Great, but am I really middle-aged and in my cello years?” And then, to his family's chagrin, he began practicing in earnest, with all the painful sounds that accompany the learning of a new instrument. Cello years, indeed!

In 2004, Ash became the chief of child and adolescent psychiatry at Emory, in addition to continuing as director of the forensic service. He is currently the only person in the United States to direct both a university child psychiatry service and a forensic psychiatry service. He is currently an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Emory. He's published over 50 papers and book chapters, and is a co-editor of the leading textbook in child and adolescent forensic psychiatry. He has held numerous offices in professional organizations, including President of the Georgia Council on Child and Adolescent Psychiatry and Vice-President of the Georgia Psychiatric Physician's Association. In AAPL in addition to his computer work, he's been a councilor and Annual Meeting program co-chair. He has won numerous awards, including the *Amicus Curiae* award of the Supreme Court of Georgia, the Irma Bland Award for Excellence in Teaching given by the American Psychiatric Association, and the AAPL Red Apple Outstanding Service Award. He is indeed an outstanding child and adolescent forensic psychiatrist and academic physician. But, as you have read in the preceding paragraphs, Peter Ash, MD, the 37th President of the American Academy of Psychiatry and the Law, is a marvelously complex, Renaissance personality whose greatest joy in life is to be of help and service to his profession, his community, his students, and his family.

When asked, “What comes next?” his response is contemplative. He wants to live life as fully as he can, not just to broaden his experience but also to deepen it; to learn, not just for his own sake, but for the benefit of others. He doesn’t have a particular goal or content in mind, but given what I know of him, I’m sure he will be pushing that envelope of mystery that drives him on.

![Figure1](http://jaapl.org/https://jaapl.org/content/jaapl/39/1/12/F1.medium.gif)

[Figure1](http://jaapl.org/content/39/1/12/F1)

Peter Ash, MD

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: None.

*   American Academy of Psychiatry and the Law

## References

1.  Ash P: The reliability of psychiatric diagnoses. J Abnorm Soc Psychol 44:272–6, 1949
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1037/h0058417&link_type=DOI) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=A1949XX09000008&link_type=ISI) 

2.  Ash P, Kellermann AL, Fuqua-Whitley D, *et al*: Gun acquisition and use by juvenile offenders. JAMA 275:1754–8, 1996
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1001/jama.1996.03530460058032&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=8637174&link_type=MED&atom=%2Fjaapl%2F39%2F1%2F12.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=A1996UP30700030&link_type=ISI) 

3.  Harvard and Radcliffe Class of 1969: Thirtieth Anniversary Report. Cambridge, MA: Crimson Printing Co., 1999