On a recent trip to Washington, I found myself seated next to a congressional legislative assistant. We began to talk and he raised some interesting questions with me about psychoanalytic practice. After reflecting on some of his queries, I decided to share some of our discussion and my later thoughts on the subject.
Increasingly there is great concern about “cost containment” in the health care field. Involved are issues of the quality of care and the costs, availability and accessibility of care. Psychoanalysis and psychotherapy have become targets for scrutiny by insurance companies and by governmental agencies and investigative bodies. They seek to obtain data that will bear upon their recommendations about inclusion of coverage in national health insurance programs.
Our Association has been monitoring all of these developments. But the time has now come for all of us to address issues of outcome, judgment, skill and effectiveness of our therapeutic work. As we survey current practices of psychoanalysts on a national scale, we find that criteria for measuring quality of care, “end results” assessment, and competency measurements are sadly lacking. These dimensions bear upon our training goals, our continuing education for competency maintenance, and our clinical research endeavors. Diagnostic decision making has been examined from time to time as our theoretical understanding has been expanded, but measures of therapeutic benefit are few and have not been systematically applied. I feel strongly that we can no longer delay addressing the issues of what benefits result from our therapeutic work, especially if we are to be involved in formulating public policy. We must be able to document successful utilization of our services, regardless of their cost, in order to demonstrate our relevance and unique contributions. Evaluation studies are not easy to carry out, and probably should not be done by us. But they should be done.
It is not my intention to criticize our field, but to call for further research, involving more rigorous methods of assessment, in an area where little has as yet been done. Participation of analysts and analysands can be obtained while still maintaining privacy and confidentiality of specific details. Difficulties in replicating studies can also be dealt with once one begins to think about such issues. Such studies may require careful examination of our assumptions, concepts, criteria, impressions and theory. The effect of improved discrimination of pertinent variables should be valuable not only with respect to insurance and funding, but more generally, and more importantly, can greatly benefit our science and general knowledge. We can learn more about disease processes and therapy, and work toward greater public understanding of our clinical work through clearer presentation of information. We need data and careful understanding of these data theoretically and therapeutically. It is my belief that our Association would do well to establish a commission to address the issues I have presented above.
George H. Pollock
Chicago