To the Editors:
In regard to the article entitled “Guidelines for Peer Review of Psychoanalysis Submitted to NIMH” (April, 1978), we are concerned that some members may misinterpret the statistical criteria for selecting cases for peer review as seeming to reflect a modification of the existing standards of the American Psychoanalytic Association's recommended frequency of not less than four analytic sessions per week.
The contract between the American Psychoanalytic Association and the NIMH called for the preparation of a set of statistical tables on patient and treatment characteristics from the April, 1976 survey on psychoanalytic practice, and required an evaluation of these data for their possible implications for peer review purposes. There are two major approaches to defining norms for care in medicine. One is prescriptive, developed by a consensus of experts in a specialty and adopted to embody optimal practice by that profession. The American Psychoanalytic Association has a set of declared and adopted principles embodied in the minimal standards for training, which are also desirable standards for patient care and are guidelines for the evaluation of applicants for certification in psychoanalysis. These optimal standards for training and certification clearly indicate, and are reflected in, the clinical practice of most psychoanalysts. To cite data from the 1976 survey: 94% of 276 patients reported to be in analysis by members of the American Psychoanalytic Association who are still in training were then being conducted on a four or more sessions a week basis, as were 81% of the analyses of more than 2,200 patients in treatment by Active and Associate Members of the American Psychoanalytic Association and 71% of analyses conducted by graduates of accredited institutes who were members of affiliate societies but were not members of the American Psychoanalytic Association.
The other major approach to developing norms for peer review is empirical and descriptive, based on the actual professional practice in a locale. Norms for review purposes throughout medicine are purely statistical norms derived from data on reported patterns of practice, and, therefore, may be somewhat disparate from optimal standards. Since the review method is intended to prevent the worse abuses, it accepts a fairly wide range of practice, sometimes even including marginal practices. The 1.65 standard deviation statistical rationale proposed to mark off the extremes from the mean for given criteria is commonly employed to stimulate peer review. Selection of cases of atypical care on the basis of statistical aberrance is not an independently reliable determination of whether the deviant care is poor. Such a determination would require review by a panel of peers considering all relevant clinical information. Outside organizations such as CHAMPUS, Medicare, Medicaid, and FEBUS may use these descriptive statistical norms to insure that patients receive care appropriate to the services billed, to control costs, and to monitor the quality of care. Our own professional organizations will, of course, continue to study and refine optimal standards to maintain and improve the quality of practice through appropriate educational procedures.
Daniel Jaffe and Daniel Shapiro, Co-Chairmen
Lee Brauer, Research Consultant
Committee on Psychoanalytic Practice