Interest in the subject of peer review for psychoanalysis has usually focused on three questions: first, about reimbursement from fiscal intermediaries (insurance companies); second, about the patient's loss of confidentiality; and third, about the distortions of the psychoanalytic process. Because the first two questions, although admittedly less important, seem to be more interesting to most analysts, they deserve first consideration. In both instances, it can be reported that peer review is alive and well.
Since 1976, when the Association was invited to contribute a psychoanalytic section to the American Psychiatric Association's first Peer Review Manual, we have been in the vanguard of the political and fiscal process by which psychoanalysis has been recognized as a subspecialty of psychiatry — distinguishable, reviewable, and hence reimbursable.
As a result, the Federal government (in its CHAMPUS Program for military dependents), a growing number of private fiscal intermediaries, some large industrial organizations, and even a few legislators are recognizing that many of our clinical activities are not arcane, but describable in language (with the help of our Manual's glossary) familiar to general psychiatrists.
Similarly, the problems of confidentiality seem to be under excellent control, judged by the almost total absence of complaints about which I have been informed. There is no doubt that the vigilance of the Association's Committee on Confidentiality has contributed substantially to this salutory situation.
One of the two primary goals in writing the Peer Review Manual was the development of a set of concepts and procedures that would have educational value. (The other was to create a tool for research.) We have attempted to break no new ground in it, intending rather to capture the conventional wisdom that psychoanalysts share about selection of patients and evaluation of whether a psychoanalysis is proceeding satisfactorily.
In our institutes, the Manual is being used in various ways. In one instance, it helps the candidates organize their diagnostic workups for supervised cases. In another, it is used to prepare cases for the second year case presentations of ongoing analyses. In these examples, note that the third party parameter has existed before the creation of the Peer Review Manual.
But, what about distortions of the treatment process? What follows is based in part upon a presentation by Dr. Freedman, Dr. Tobin, and me at the Panel on Psychoanalytic Practice at the Association's Annual Meeting in 1977. It has been suggested that patients need to be informed when their psychoanalysis is being supervised, recognizing that their psychoanalysts have personal goals as well as therapeutic ones in treating them. All of this is familiar, as are the primal scene possibilities when patients feel left out of the supervisory relationship.
What is new and troublesome about the current Peer Review scene is the explicit nature of the third party parameter and the patient's knowledge that a written report is required. A patient may easily infer that other students, as well as the psychoanalyst's supervisor, may know about them; but the presence of the fiscal intermediary and the requirement for a written report seems much more troubling.
I suspect this may be because it is more difficult for both psychoanalyst and patient to repress its presence. The objection that Peer Review is completely different from supervision or case conferences because the supervisor or other candidates are only present to serve the patient's interest fails to consider the multiple ambitions of all parties.
Since 1976, the question has frequently been asked about the most suitable method for integrating a written report into an ongoing analysis. It seems to me that at the present level of our knowledge, personal style combined with one's best clinical judgment affords the best guideline. In any event, it is the analysis of the consequences that is crucial.
Two relatively opposite techniques, both of which are feasible, have been used. First, one may tell the patient, “The report belongs to you, but I will only give it to you when your analysis is finished, because giving it to you now would not help your treatment.” Second, the patient (especially a candidate in a training analysis) may be asked to recommend what answers he or she wants to be communicated. In this connection, one might ask if any candidate has ever shared his or her periodic reports to the Institute of a supervised analysis with the patient, and how often analytic supervisors share their institute reports with their supervisees.
Psychoanalysts most commonly explain their anxiety about writing psychoanalytic reports in terms of examination anxiety, as a derivative of castration fear. A different level of anxiety stems from our correct anticipation that society in general views our work as mysterious and therefore not susceptible of rational explanation. This view reflects the outsider's fascination with and fear of the “mysterious,” i.e. unconscious, aspects of his own nature. On further scrutiny, this sense of mystery has often turned out to be a manifestation of a regressed primal-scene fantasy about what occurs in our relations with our patients.
The phrase “regressed primal-scene fantasy” is not intended to refer to the child's reaction to seeing or hearing the parents' actual sexual intercourse. In contrast, it refers to the child's developmental response with age-appropriate primitive fantasies even to enlightened and
empathic explanations about sexual matters.
Children use projective identification to deal with the pain of feeling left out of the parents' tender interactions. Unconsciously, this takes the form of, “If I don't understand it, I will make them be like me.” Thus the child creates a primal-scene fantasy of oral-incorporative or destructive or anal-sadomasochistic or phallic exhibitionistic-voyeuristic interactions, depending on his developmental level and then identifies with one or the other of his parents in the fantasy.
Third parties are likely to do the same, when they hear or read about us with our patients and insist on making it mysterious. Thus the analyst may be appropriately wary that the tender concern he feels for his patients may be perceived in a regressed, primal scene way by fiscal intermediaries and peer reviewers. Similarly, we may react to the third party's perception of the “mystery” of our work by feeling ourselves to be an elitist group in society, the “keepers of the secrets.” For this pleasure, we are willing to pay the price of the depreciation commonly expressed, for example, in jokes about psychoanalysts.
For analysts as well as patients, the developmental stage of desexualized concern between two adults is difficult to maintain after it has been achieved. However, the psychoanalyst's reaction to the third-party parameter and its countertransference implications provide a unique opportunity to scrutinize “the emotional position of the analyst” for an understanding of all aspects of his concern for his patients.
Finally, what about the Peer Review Manual as a tool of research? It is believed at one institute that the Manual will prove valuable in providing a standard set of data on patients selected for supervised analyses. In addition, in workshops sponsored by CAPE it was proposed that the Manual could provide a framework within which cases can be organized for various purposes: for institute courses or reports, for the certification process of the Association, and for comparing patient characteristics that correlate with therapeutic outcome on a nationwide basis.
William Offenkrantz, M.D.
Milwaukee