It is both timely and appropriate that the American review the issue of peer review in psychoanalysis. As the major body responsible for standards, training, and certification in adult and child analysis in this country, we are the logical organization to establish indications for analysis, to define what constitutes proper analysis, to say who is a competent analyst, and to establish appropriate ethical claims review and peer review standards, safeguards, and procedures.
At the present time, enormous difficulties confront the psychoanalyst when faced with the necessity of submitting to a peer review procedure. These difficulties are personal, professional, educational, and political, and the current situation frequently leaves the well-intentioned analyst in a position where he or she feels forced to make decisions that could intrude on the patient, the analyst, and the profession's best interest.
It is therefore not enough to strive within the framework of other groups to achieve our goals, as many of our hardworking members have done. We cannot leave these crucial matters to other groups. It is essential that we actively pursue a leadership role in this area — so vital to the welfare of our patients and to our profession — lest by default we be overtaken by events.
As matters now stand, analysts, candidates, and patients alike face a bewildering array of proliferating claims and peer review processes and procedures. These vary from one insurance company to another, from one contract to another, from one year to another, from state to state, from society to society, and from one professional group to another.
In some quarters, peer review originally referred to a review by peers (colleagues) of a case brought to medical psychiatric attention by an aggrieved patient, family, lawyer, or such. Now, however, the term usually refers to an insurance claims review as described in the January, 1980 revised American Psychiatric Association CHAMPUS Manual for Inpatient and Outpatient Claims Reviews, fashioned originally to address CHAMPUS and Aetna requests. That manual specifically prescribes that a psychoanalytic case be reviewed by a panel of three psychiatrists and one psychoanalyst. How a psychoanalyst is defined, what his or her credentials are, and who has the authority to establish such credentials is unclear. A biological psychiatrist can check psychoanalysis under this system.
In 1975, the Baltimore-District of Columbia Psychoanalytic Society in conjunction with the Washington Psychoanalytic Society prepared peer review standards for psychoanalysis of adult, child, and adolescent patients. Among other considerations, they indicated that
since all correspondence may be shown to the patient, reports should be kept as brief and nonspecific as possible. They also stated that peer review of psychoanalytic treatment should be done by peers trained in psychoanalysis and all subscribers to insurance plans should be informed by the carrier from the beginning that medical treatment is subject to peer review. These standards are not to be confused with the “Guidelines for Psychoanalysis” in the American Psychiatric Association Manual of Psychiatric Peer Review.
A further complication: the D.C. Mental Health Information Act reduces the amount of personal information that can be given by a psychiatrist to an insurance company.
To add to the confusion, in D.C. (but not in Virginia or Maryland) through the written procedures of the D.C. Medical Society and Washington Psychiatric Society, a psychoanalyst faced with a claims review may request a peer review by three certified American Psychoanalytic Association psychoanalysts. If it is a child case, at least one must be a certified American Psychoanalytic Association child psychoanalyst. These analysts report to the Peer Review and Utilization Committee of the D.C. Medical Society.
Review may destroy the very treatment it is supposed to assess.
Currently, a medical nonanalytic group is preparing “peer review standards for child and adolescent psychoanalysis.” The noncertified analyst who drafted them feels strongly that certification by the American is inadequate to attest to an individual's competence. Peer review here means by nonanalysts as well as analysts. This so-called peer review is believed to be the best protection against “fly-by-night analysts” as well as against the selection of psychoanalysis as the treatment of choice over some of the “newer treatments” now available. Indications for treatment are on the basis of symptoms, not diagnoses, and psychoanalysis is considered a treatment of last resort. Another nonmedical analytic group is also now addressing peer review issues.
So a practitioner in the Maryland-D.C.-Virginia area must deal with this confusing maze, and the American's own
efforts thus far, while a great improvement over other procedures and sincerely well intentioned, do not solve the dilemma. Many of the complex legal, ethical, technical, and procedural (including timing) issues remain insufficiently addressed.
And what of our patients? How does all of this affect them and their treatment? As analysts, our first obligation and primary medical responsibility is to protect our patient's treatment. At the same time, we are not unaware of the economic realities of our patient's lives, and we try to facilitate reimbursement. But often our hands are considerably tied in our practical negotiations on their behalf by a therapeutic need for a relatively low profile in respect to our patients, as well as the ever-present crucial requirement regarding confidentiality.
Child and adolescent analytic patients present special problems. Often, assurance of absolute confidentiality is a crucial part of the original verbal contract between analyst and patient. It is both developmentally appropriate and necessary. Even parents may not be seen in some instances. Adults have the right to waive confidentiality. Do children have the maturity to do so? And what if they refuse to waive it?
In my experience and that of many colleagues, peer review in its current form is having an increasingly significant detrimental impact on the practice
of adult, adolescent, and child analysis—on availability of patients, on candidate training and supervision, and on various aspects of the psychoanalytic process itself. At best, it is an intrusive, disruptive, distracting, time-consuming process (thereby prolonging treatment and increasing costs). At worst, it is destructive of the very treatment it is supposed to assess, and sometimes of the patients we are trying to help.
Some insurers withhold payment while cases are reviewed; some procedures (in this age of computers) fail to adequately protect the patients confidentiality despite claiming to do so; some companies demand early, frequent, in-depth, detailed information about conflicts, transference, genetics, symptoms, and more. Sometimes there is only one reviewer. There have been reviewers who go far beyond the process of peer review, and improperly disrupt and undermine the analytic process with supervisory comments, premature interpretations, and criticism of the practice of sharing material with the patient. The patient, of course, sees this; the analytic process is adversely affected. Too often, patient and analyst have little or no recourse, if the analysis and payment are to continue.
Sometimes a patient (especially a wealthy and influential one) may fare reasonably well. If a peer review process is too intrusive, burdensome or difficult, they change insurance carriers or do without insurance altogether. Many
patients, however, especially those less wealthy or knowledgeable about insurance, having signed a contract because of their need for treatment, suffer silently and helplessly at the hands of the insurers peer reviewers, and well-meaning analysts who are supposed to help them. Anxiety and shame, the nature of their illness, and fear that treatment or funds would be withheld prevent them from coming to their own defense, as they could with other kinds of illness.
Transferences are skewed, sometimes irreparably, as analysts take a real role in their patient's lives. The analyst's collusion with the patient on the one hand, and with the insurers on the other, form powerful resistances and delay the work. Defenses are strengthened as material contained in the reviews is discussed and debated. The therapeutic alliance can be jeopardized or even destroyed. Crucial sensitive conflictual material, perhaps having appeared only after years of work, disappears—sometimes for years, sometimes never to return—in the face of threatened repetitive intrusions and exposures. Some patients simply terminate their analysis prematurely. Others continue angry, defended, wary.
We should not blame the insurance companies or other groups, medical and nonmedical. They are all acting openly in their own behalf. The responsibility to psychoanalysis and to our patients is ours. We need to come to grips with the difficult professional, educational, and political issues involved in drawing up our own set of indications, procedures, and standards and vigorously assert our case to implement them. If we do not, other groups will.