Dr. Altschul is Chairman of the Peer Review Committee.
Peer review has been an integral part of our profession from the beginning of psychoanalysis. Discussion of case material, both in public and private, has been a source of our scientific and educational development. In 1974, during the presidency of George Pollock, two ad hoc committees, the Peer Review and the PSRO Committees, were formed by our Association to address some of the sociopolitical, economic, and scientific issues that were arising which had the potential to affect psychoanalytic practice.
Government regulations were being enacted for programs supported by federal funds. Review bodies were to be established on a national and local level, to be called Professional Standards Review Organizations (PSRO.). These bodies were to function to insure quality care and regulate expenditures in programs such as medicare, medicaid, and maternal and child welfare. In addition, there was widespread pressure for accountability from all third party sources of reimbursement.
The charge to these committees was identical: to establish a set of national standards for psychoanalytic practice endorsed by the Association, which could serve as the basis for similar local standards. Other charges were to communicate with local societies and institutes to urge them to set up local committees and to establish a network of representatives to maintain liaison with the local entities and other national groups. By 1978, these two committees were combined and made a standing committee of our Association to be known as the Peer Review Committee.
Much of the early work of the ad hoc committees was done jointly, so I will speak about the activities and accomplishments as if they were of one committee. All of the activities of the committee were carried out with the charge of the President in mind, and continue to be done for the scientific, educational, and professional interests of our Association.
In keeping with the main charge of the committee, two task forces were formed. One sought to establish diagnostic criteria for analyzability, the other to establish process criteria for ongoing psychoanalytic treatment. These were done in cooperation with several members of the Academy of Psychoanalysis and became part of the Peer Review Manual of the American Psychiatric Association. The first edition of the manual contained the diagnostic criteria and the second edition added the process criteria. In our continuing efforts to serve the best interests of our Association, the committee will now direct its attention to the development of guidelines for use in claims review for insurance purposes.
Another educational effort took place when in December, 1978, the Executive Committee formed an ad hoc subcommittee on DSM-III of the Peer Review Committee to write a chapter in a companion volume to DSM-III on treatment planning. Ultimately a volume entitled Treatment Planning in Psychiatry, edited by J.M. Lewis and G. Usdin, was published by the American Psychiatric Association in 1982. The chapter on psychodynamic psychiatry was written by the above subcommittee and representatives of the Academy of Psychoanalysis. Although it was not published as a companion volume to DSM-III, it allowed our Association to have an input into what kinds of information beyond the DSM-III diagnosis were needed to adequately plan for psychoanalytic or psychoanalytically oriented psychotherapy.
To facilitate communication with the local societies and institutes, we have developed a network of peer review representatives which meet at both the spring and winter meetings. Discussions range widely and reports reflecting local issues and situations are made by society representatives. Problems and successes are shared and the input of the committee and the representatives has proven invaluable on numerous occasions to particular areas around the country which are encountering peer review difficulties.
It is through these meetings and our work on the Peer Review Manual that several affiliate societies have been helped to maintain and foster coverage for psychoanalytic treatment. In one case, a lawsuit by a subscriber was won on the strength of meeting the criteria for psychoanalysis outlined in the Peer Review Manual.
One especially important aspect of these interchanges is to encourage psychoanalysts to become active in the district branches of their psychiatric associations, since peer review panels are appointed through the district branches. This is essential if psychoanalysts are to be the reviewers of psychoanalytic treatment and thus provide true peer review.
Minutes of the network meeting are distributed to all affiliate society presidents and representatives so that the information discussed is made available to all members. One of the results of such dissemination of information was that a member of the American whose psychoanalytic case was being reviewed “in house” by an insurance company requested review by our own Peer Review Committee. We were able to arrange a review in that case.
We have agreed in principle to review
cases of members of the Association and graduates and candidates of institutes approved by the Board on Professional Standards. To avoid overlap, we have agreed to do so only with insurance companies that do not have a contract with the American Psychiatric Association. Along these lines we have made the recommendation through the network of affiliate society representatives that psychoanalysts should always request review of ongoing psychoanalytic cases be done by psychoanalysts, even when the review is being conducted under the auspices of the American Psychiatric Association.
Early in the functioning of the Peer Review Committee we began to hold programs at the spring and winter meetings of the Association, listed as the “Open Forum on Peer Review.” Here, any of our members may learn and participate in open discussion on any and all of the issues stimulated by peer review. We have taken up such topics as confidentiality, the educational use in institutes of the criteria for analyzability and process criteria developed for the Peer Review Manual, how to write up cases for peer review (at one meeting we used the case of the Rat Man to compare methods of writing for peer review), the use of an alternate method of diagnosis for claims review, and the effects on the process of the psychoanalytic treatment as a consequence of peer review.
We have had a variety of cases presented where the effects have seemed to stir up issues or potential problems, but also cases where review procedures seem to have facilitated the analytic process. One such case was recently published in the Journal of the American Psychoanalytic Association. In discussions both at the network and the Open Forum we have been evolving methods of writing up cases for peer review that involve creative ways to include the patient and preserve confidentiality.
Problems resulting from peer review of child psychoanalytic cases have recently come to our attention and we will be directing energy in that direction. Peer “review of child psychoanalytic cases was the subject of the Open Forum at the December, 1984 meeting. In addition, the committee itself will begin to focus its attention on developing guidelines for peer review of child psychoanalysis. The Open Forum is now being held only during the December meetings of the American while the meetings of the committee and the network of representatives are held twice yearly.
The committee will continue to develop and improve the Association's guidelines for peer review and to maintain and improve communication with affiliate societies. Both the societies and the American benefit from maximizing communication and the ability to mobilize the membership to action when needed.