I am a consultant to and past member of the American Psychiatric Association's Peer Review Committee. I have additionally been a member of the American Psychoanalytic Association's Peer Review Committee. In these capacities, I have had the opportunity to evaluate the impact of peer review on psychiatric care in general and, more specifically, on analytically oriented psychotherapy and psychoanalytic treatment.
I have observed that in most instances the use of peer review by third party payers has not presented a significant interference in the treatment process. Confidentiality has been excellently maintained, and the review by our peers has been appropriate and, in some instances, valuable. I do not find this surprising. The same could be said of the supervision of a candidate's control case.
It is my opinion that, when supervision causes a problem and adversely affects the treatment process of a control case, it has to do with problems stirred up in the candidate that are of an intrapsychic nature.
In a few instances, I have seen a similar phenomenon relating to cases of psychoanalytic psychotherapy and psychoanalysis being done by fully trained psychoanalysts. It seems that the analyst is for one reason or another in these cases personally uncomfortable with the review process. This discomfort is either picked up by the patient or is told to the patient. I have seen instances of patients being led to become fearful of this process by the therapist and being given a misleading concept of it. Then it may well interfere with the treatment process. In those cases, I feel that the problem is iatrogenic and does a disservice to the patient.
If there is to be any third party payment for psychoanalysis in the future, peer review will continue to be a fact of life. I believe it is in the best interest of psychoanalysis and our patients that we as analysts come to terms with this reality so that our own fears and anxieties do not cause our patients' problems. We need to be able to present the peer review process in a reasonable and unbiased way to our patients to help allay their fears. I believe that this is true with peer review process just as it is true for the control case supervision process. Our patients certainly have enough problems without our introducing more.
Gary L. Shepherd, M.D.
La Jolla