In September, 1977 the American Psychoanalytic Association guidelines for Peer Review of Psychoanalysis were submitted to the NIMH to fulfill a contract to supply statistical tables drawn from the April, 1976 Survey of Psychoanalytic Practice. The contract, obtained from the Division of Mental Health Studies Programs, requested data 1) on certain patient characteristics; e.g., demographic data, previous treatment, diagnosis, prognosis, level of initial impairment, and changes in level of functioning as correlated with length of treatment and treatment modality; and 2) on specific treatment characteristics, such as cost, frequency, insurance coverage, and length of session. A lengthy report reviewing the implications of this data for peer review purposes was written by Daniel Shapiro, M.D. and Lee D. Brauer, M.D., research consultant, in consultation with the Co-Chairmen of the Committees on Peer Review and Professional Standards Review Organizations. Some of the findings have been made available to the President's Commission on Mental Health and are being included in governmental policy deliberations as to National Health Insurance.
The report urged that cases only be targeted for review if there are indications that the care is unusual or aberrant, rather than by random selection. The authors proposed selecting cases 1.65 standard deviations from a given mean in order to provide a reasonable chance that the care is atypical, for variables distributed normally in a population. This criterion would earmark about 4.5% of cases above the mean and a similar percentage below the mean as targets for possible review by a committee of psychoanalytic peers. While pointing the finger at the atypical case puts a premium on conformity and militates against innovation, selecting the nonconforming case may reduce the intrusion of the review process upon average and above average professional care.
The atypicality principle would not apply to the recommendations for the diagnosis of analyzability embodied in the Manual for Psychiatric Peer Review or to its confirmation after one year of analysis and an initial assessment of the psychoanalytic treatment process. However, on the basis of the mean length of psychoanalyses nationally, yearly intervals for further concurrent review of the analytic treatment process seemed an excessive requirement. Half of the mean length, 27 months, was a more logical interval; the mean duration extends for 848 sessions or 53 months.
Utilization review committees should not be required to develop regional norms or norms state by state for duration of treatment for analysis, nor for the other modalities of treatment psychoanalysts employ in office practice. Type of treatment and diagnosis far overshadow region as factors determining variation in duration; regional deviations are only minor.
Dallas is hoping to strengthen and expand its present analytic community, with the ultimate aim of establishing a new Training Institute. Analysts and especially Training Analysts who might be interested in relocating in a sunny and welcoming climate where analytic practice can flourish are invited to contact Dr. Kenneth Z. Altshuler, Chairman of the Department of Psychiatry, Southwestern Medical School, 5323 Harry Hines, Dallas, Texas 75235.
Applying the criteria of 1.65 standard deviations from the mean for possible review of cases for extended duration of care, treatments could be targeted after 7 and ¾ years of analysis for most diagnostic groupings. The treatment of obsessional conditions, narcissistic states, and the borderline pathologies would be no longer than the treatments of the other neuroses and character neuroses.
As provisional norms to be used as standards for care, the authors proposed:
A frequency norm of three or more sessions per week.
Session length of 45-50 minutes.
No major modifications from the analytic treatment process, such as the use of concurrent medication.
As provisional norms for assignment to psychoanalysis:
An age norm of under 50 years at the time treatment begins. If the analyst has not received additional training in child or adolescent analysis, possible review of cases begun when the patient is less than 17 years.
Conditions diagnosed as transient situational maladjustment, adult adjustment reactions, social maladjustment without psychiatric disorder, certain diagnoses associated with organic conditions, psychoses, or given a primary diagnosis of alcoholism or drug dependence are atypical.
Only 4% of the patients of psychoanalysts fall into these categories; less than 8% of patients given these diagnoses end up in analysis in office practice.
The first of a series of interim progress reports on the survey findings is being prepared. It will cover the study of the factors leading to identification with the profession, to active and inactive analytic practices, and to satisfaction or discontent in career. Committee members are reviewing data on referral sources and additional interim reports will be issued as the data analysis proceeds in stages. The investigations are being conducted at the Yale Computer Center by Dr. Brauer, who is coordinator in the Mental Health Evaluation Training Program at the Center for the Study of Health Services at Yale University and by Dr. Philip Leaf, a research sociologist holding a postdoctoral training fellowship, under Dr. Shapiro's direction. Funds for these statistical investigations were provided by a $6000 grant from the Executive Council at the last meeting.
Daniel Jaffe and Daniel Shapiro, Co-Chairmen
Committee on Psychoanalytic Practice