In a July, 1982 Viewpoint I wrote for this Newsletter, I noted three areas of concern for psychoanalysts that have continued to the present. They were (1) whether psychoanalysis would be supported by health insurance; (2) whether there would be violations of the patient's privacy by virtue of reports being placed in the hands of insurance companies; and (3) what distortions might be introduced into the analytic process by this “third party parameter.”
My viewpoint then and now is that peer review is more than a necessary evil. It can work and is working, despite problems that are being worked out. Not only does it not seem harmful to patients, but in many instances it can have a useful effect on the treatment process—in the same way that any effort to reflect upon that process can be useful to both patient and analyst.
Since 1982, I have continued to serve as an informal “clearing house” for the exchange of information about analysts' relationships with peer reviewers and about difficulties in general introduced into analyses by the “third party parameter,” in the form of a fiscal intermediary. I have worked closely with the American Psychiatric Association's (APA) Office of Peer Review and with the medical directors of many insurance companies.
In these three years, I have been impressed by the flexibility of the medical directors of many of the twenty-six insurance companies which have signed peer review contracts with the APA. Their collegial curiosity has been coupled with a willingness to learn about our criteria for selecting patients for analysis, and respect for the completeness of our criteria for reviewing ongoing psychoanalytic cases. These attitudes have occasionally been laced with an adequate degree of anxiety about facing indignant policyholders if they terminate benefits for adequately documented analyses.
An additional common problem of medical directors is their loyalty to the medical profession and identification with the practicing analyst, in conflict with loyalty to their employers. On a more abstract level this becomes acutely painful when the tension is between the goals of cost containment and quality control.
Overall, my impression is that psychoanalytic patients have not fared as badly as many of us had feared they would. This has been true despite occasional horror stories. When these occur, however, there are usually specific remediable causes. Following are some of the more frequent causes of difficulties that I have seen. First, sometimes requests are made to analysts for psychoanalytic information that fail to specify the need to use the Psychoanalytic Peer Review Manual. Second, sometimes reports are submitted by analysts that reveal little more about the treatment than their “M.D.” credentials.
Third, occasionally analysts have failed to exercise appropriate vigilance in District Branches of the APA, as a result of which unqualified psychiatrists have designated themselves to the APA's Office of Peer Review as competent to review cases of ongoing analyses, and then these self-designations have been sanctioned by District Branch Presidents. This has occurred despite the fact that, since
1983, the APA Peer Review Office has made a sincere effort to refer ongoing psychoanalytic cases to one or more analysts. Fourth, there have been rare, but always painful, breaches of confidentiality, such as administrative personnel at insurance company offices failing to “sanitize” a record before sending it for peer review. Fifth, sometimes insurance companies have denied payment of a patient's psychoanalytic claim without asking why the treatment is four or five times a week.
The foregoing examples suggest there is more than enough room for error within each component in the system. However, it does seem to be working, when judged by the criteria that (1) our treatment has by and large avoided arbitrary limits (“caps”), (2) many patients have had analysis who would otherwise not be able to afford it, and (3) by the absence of anecdotal evidence that patients' analyses have been significantly damaged by the peer review system.
An additional salutary development which has already further improved the system is the fact that a second Peer Review Office has been set up, “within” the Association's central office, supervised by Dr. Sol Altschul of Chicago, with the enthusiastic support of the APA's Peer Review Office. There have been several cases of psychoanalysis reviewed, with reviewers selected by Dr. Altschul, and reimbursement for the reviews provided by the insurance company.
As I have suggested previously, it is a mistake to allow nonanalysts to review ongoing analytic treatment. In my 1982 Newsletter article, I shared some of my continuing observations concerning the “outsiders” review of psychoanalytic treatment. Members of society in general, third party payers in particular, many members of the medical profession (including medical directors of insurance companies), and even peer reviewers who are general psychiatrists all view analysts as practicing in mysterious ways. This attitude reflects their fascination with, and fear of the “dark side,” the unconscious aspects, of their own minds.
This insistence that analysts practice mysteriously is a way of avoiding confronting and understanding the everyday existence of any unconscious attitudes in themselves. More specifically, this attitude also often seems to reflect a primal scene fantasy about the relationship between analysts and their patients. I do not use “primal scene” to refer merely to a fantasy about a specific act of sexual intercourse. Just as children do (even in response to enlightened
and empathic explanations about sexual matters) to avoid feeling left out of parental interactions, so do many of these reviewers distort the analytic relationship into a fantasy one—often sadomasochistic, exhibitionistic-voyeuristic, or other such distortions.
To the extent that we ourselves enjoy the exalted status conferred upon us as keepers of the keys to these secrets, we are encouraging the depreciation that inevitably follows the exaltation. For such arrogance, analysts must be willing to pay the price commonly expressed in derogatory jokes about our specialty, as well as in the fantasies I have just referred to. These attitudes have been expressed repeatedly by peer reviewers who are general psychiatrists, by administrative personnel throughout the system, and particularly by medical directors of insurance companies, with the exception of the one I know who is a graduate analyst.
Not only nonpsychoanalytic reviewers introduce problems into the review system; we have found that any peer reviewer may introduce problems as an aspect of their role as a potentially powerful judge, even though their opinions are always advisory and there is usually a group of two or three reviewers. Intense conflicts about competition may be reawakened, following which direct expressions of hostility may surface, or unconscious defenses may predominate. Commonly these are reaction formations, such as rescue fantasies toward the analyst, perhaps taking the form that the practitioner needs to be educated. Or they may be directed toward the patient who the reviewer believes needs to be saved from an incompetent practitioner.
I believe that peer review is necessary, potentially but not usually harmful, and may even be useful … a major problem is its impact on the analyst; when this is recognized, we can find ways to deal with it.
In addition, loyalty conflicts between allegiance to a fellow practitioner and to the agency paying the peer reviewer may be stimulated in a way that rekindles old sibling rivalries and split parental loyalties. The reviewer may also have a conflict which is the other side of the coin of analysts' wishes and fears about exhibiting their relationships with their patients. That is, the reviewers may be in conflict about looking at and feeling left out of this uniquely intimate relationship, as I indicated above.
An interesting case report in 1984 by H. Rudominer (Journal of the American Psychoanalytic Association, Vol. 32, No. 4, pp. 773-797) not only deals with some of the issues I have named in greater depth, but offers worthwhile insights for any practicing analyst into the vicissitudes of analyzing the genetics and the transferential nature of this third party parameter, including the patient's primal scene reactions, the countertransferences, the analyst's problems with peer review, and perhaps most importantly, how the peer review process helped the analyst deal with some important therapeutic issues.
This case report also corroborates a frequent finding I have heard in many anecdotal reports from other analysts about patients whose treatment has been peer reviewed. One often sees recreated in the transference the patient's history with multiple, simultaneous authority figures, and the loyalty problems that arose at such times. This is especially true if the patient learned to deal with various anxieties by setting one parent against the other. The patient can relive that experience in the transference by attempting to conspire with the analyst against the third party or peer reviewer as “the other parent.” Similarly, the patient, experiencing the analyst as a sibling, may invite him or her to unite against both “authoritarian parents”: the third party payer and the peer reviewer. If the analyst understands and can make use of such fantasy distortions of the peer review procedure, the analysis can be facilitated.
In conclusion, I believe that peer review is necessary, potentially but not usually harmful, and may even be useful. However, a major problem is its possible impact on the analyst; when this is recognized, we can find ways to deal with it.
As analysts, we constantly struggle to achieve the ideal of finding the most highly integrated ways of dealing with our own tensions, thereby enabling us to treat our patients in pursuit of healing and truth, rather than some form of infantile gratification for ourselves. Inevitably, we cannot always achieve this ideal. When this happens, we become vulnerable to more primitive forms of relief of anxieties and of gratification, both with our patients and with other analysts.
Peer review procedures challenge such ideals in potent ways and increase such vulnerabilities and dangers. I believe we can achieve the goals of treating our patients properly and pursuing truth, only by a mixture of mutual support and confrontation. This can be greatly facilitated by frank discussion of our peer review experiences with other psychoanalysts in small groups.