Chairman, Task Force on Research and Information and Chairman, Committee on Government Relations and Insurance
Those of us who have experienced psychoanalysis know that it works. The changes it has made in our lives and our patients' lives could not have occurred by any other treatment method.
The rest of the world does not know it. Due to the nature of our work, and perhaps our temperament, psychoanalysts work quietly and out of the limelight. Our patients also wish to keep this privacy. Fascinated as analysts are by the boundless possibilities of human nature, we enjoy communicating among ourselves, and our literature is rich in clinical insights. We have little patience for the phenomenological statistical studies by which outcomes are measured in other fields of medicine.
Unfortunately, the world we live in is changing drastically. Expensive technology and the aging of the population are causing overall health care costs to soar. The political environment favors unbridled competition as the remedy, an experiment in social Darwinism. Biological reductionism in psychiatry appeals to the young people among whom we look for future psychoanalysts. Situations like the Oscheroff case (where a hospital was sued for treating a major-depressive patient with psychotherapy rather than medication) provoke both our friends and our critics to demand that psychoanalysis prove its efficiency in the same manner as competing treatment methods. Psychoanalysts who work in a general psychiatric environment feel the pressure keenly.
The challenge goes far beyond economics and third-party payment for psychoanalysis; it touches on the fundamental issue of the status of psychoanalysis as a treatment method in the eyes of psychiatry and medicine. Therefore, we as psychoanalysts have a responsibility to document and communicate what we know. We are not exempt from the current demand for accountability.
In March of 1988, following recommendations of the Committee on Government Relations and Insurance, the Executive Committee established the Task Force on Research and Information (TFRI). It was charged with answering three questions: 1) What do we already know about the efficacy of psychoanalysis as a treatment? 2) How can we as a profession devise and implement efficacy studies that will meet rigorous modern scientific standards? 3) How can we effectively communicate what we know to those who make economic and professional decisions crucial to the future of psychoanalysis?
The three-person TFRI coordinates the work of three committees relevant to the project: the Committee on Government Relations and Insurance, the Committee on Public Information, and the Committee on Scientific Activities. Norman A. Clemens, M.D., of Cleveland, Arthur J. Farley, M.D., of Houston, and Paul W. Mosher, M.D., of Albany, respectively, serve as liaisons to the committees and make up the Task Force.
The scientific task of evaluating existing efficacy studies has to be scholarly and objective, free from any hint of influence by advocacy concerns about influencing economic decision-makers. Only in this way can the review command the respect of both psychoanalysts and non-psychoanalytic scientists.
The assignment was delegated to a Sub-comittee on Efficacy Research of the Committee on Scientific Activities, consisting of Henry M. Bachrach, Ph.D. (New York), Chairman, Robert M. Galatzerr-Levy, M.D. (Chicago), Alan Z. Skolnikoff, M.D. (San Francisco), and Sherwood Waldron, Jr., M.D. (New York). Dr. Bachrach initially served on the TFRI but was replaced by Dr. Mosher in order to maintain the desired separation of functions.
There is more literature on efficacy of psychoanalysis than one might assume. Efforts at statistical tabulation of outcomes were made as early as 1917. In the past two decades prospective studies have been published by major psychoanalytic academic centers covering hundreds of patients. The review of all available studies is expected to appear as a monograph approximately within a year, following approval of the Committee on Scientific Activities.
Intriguing trends emerge from the studies. The majority of patients selected as suitable for psychoanalysis achieve distinct therapeutic benefit from treatment, whether completed or not. Patients who complete their treatments show a substantially higher rate of improvement than those who do not. Patients judged by strict standards to have effectively engaged in the psychoanalytic process (slightly less than half) achieve greater improvement, by a considerable margin, than those who do not. In other words, the studies demonstrate that psychoanalysis with patients able to use it well and to carry it through to termination accomplishes distinctly superior results.
A noteworthy finding was that in groups of patients, carefully selected for their suitability for analysis, factors could not be distinguished that would predict which individuals would successfully engage in the psychoanalytic process.
Despite encouraging and important results, the available studies leave a great deal to be desired, which will be part of the basis of recommendations for future studies.
The hard work of researchers is being matched by the efforts of the communicators.
Last fall the Task Force met with Irvin L. (“Sam”) Muszynski, an attorney who may be familiar to some of our members from his previous work as a key staff member of the Office of Economic Affairs of the American Psychiatric Association. This consultation turned out to be very fruitful in developing our strategy.
Mr. Muszynski strongly supported our emphasis on hard data and accountability to buttress the established position of psychoanalysis as a medically necessary and effective treatment methodology. Its unique advantages to certain groups of patients justify its intensity and cost. The cost of a year of psychoanalysis pales beside some of the big-ticket items created by modern medical technology.
Quality control has been built into the profession, as APsaA has rigorously maintained high standards in its training programs, certification procedures, and post-graduate education. The length and cost of psychoanalytic training preclude any chance of flooding the marketplace with qualified psychoanalysts, so our portion of the health care dollar is very small.
Despite its lively ferment of internal debate, psychoanalysis is relatively homogeneous and consistent as both a body of knowledge and a treatment method. Our theories may vary; our fundamental investigational and therapeutic
tool of creating the environment for patients to explore and gain mastery over their mental life remains as a core.
Our first priority is to keep what we have — access to the self-paying patient and good third-party coverage where it exists. The intrusiveness and “quick fix” expediencies of most “managed care” plans create an environment hostile to the protected setting and open-ended commitment that are vital to psychoanalysis. Yet, there may be some enlightened managed-care executives or employers who are truly concerned with providing what is best for each patient who could be persuaded to make psychoanalysis available when the need leaves no alternative.
Developments that are hostile to psychotherapy in general must be vigorously opposed. Our numbers are quite small, so that we can achieve the most through integrating our efforts with the psychiatric and medical organizations. However, we must be prepared to act independently where necessary.
The Task Force is preparing informational materials that can be used with health care decision makers. The bulk of health economics decisions are made by employers, benefit managers, insurance executives, legislators, and government administrators.
In addition to presenting psychoanalysis and the necessity of an open-ended, safe environment in which it can take place, the materials will include hard data on the additional cost of good health insurance that would provide for analysis. Actuarial figures have been prepared for us by Edwin C. Hustead of Hay-Huggins, a national expert on mental illness insurance. The American is also obtaining information on the experience in countries where national health plans cover psychoanalysis on a par with other medical treatment. The efficacy data already available are significant in meeting the needs for accountability.
To coordinate action at the local level, the Committee on Government Relations and Insurance has developed a Network of analysts active in these issues around the country. By sharing experiences and coordinating efforts and resources, we hope to optimize results. The Network had its first meeting in New York in December 1988, and its second in San Francisco in May 1989. Anyone interested in participating in future meetings of the Network may contact the Central Office.
The Committee on Public Information, under its chairman, Stephen Sonnenberg, M.D., (see Interview, page 16, of this issue of the Newsletter), had already developed a Public Information Network to carry on educational activities that require a broader focus on the general public.
Rapidly moving developments prompted by the Resource-Based Relative Value Scale (RBRVS) have brought about unusual opportunities to revise the AMA's Current Procedural Terminology (CPT). It now appears likely that there will be a distinct procedure code for Medical Psychoanalysis, a clear asset in achieving better definition of psychoanalysis as a mainstream medical treatment modality. Future RBRVS studies would be enabled by the separate code to take into account the unique factors of training costs and intensity of treatment effort in establishing the relative value of psychoanalysis for reimbursement purposes. Intense deliberations of the Committee on Government Relations and Insurance and consultations with the APA and other psychoanalytic groups have gone into the decision to support a distinct code and to influence the way in which it will be presented in the CPT.
As we develop these resources to support the case for psychoanalysis, the American will be in a better position to approach the government officials and major employers and insurance executives who make health care policy decisions on a national level.
Dr. Bachrach's Sub-committee on Efficacy Research has noted that as early as 1943 Oberndorf succinctly stated the challenging questions that still need to be answered. To paraphrase, what type of treatment is best suited to what kind of patient, suffering what kind of illness, at what point in his or her life, when treated by what kind of analyst, in what manner? These are of great technical importance to psychoanalysts and non-psychoanalysts alike, and it will take many more studies to answer them to our satisfaction.
At this time the Task Force on Research and Information is particularly charged with seeking the level of answers that is needed in the “outside” world of psychiatry, medicine, and health care economics. This level deals more with “whether” psychoanalysis works and “for whom” than the “why” and “how” questions that we as analysts find more compelling. The shortcomings of the existing studies point to certain conditions that a new, even more useful study will have to meet.
That study must be prospective, consider work with experienced analysts rather than candidates, study typical analytic patients, have a large enough group of patients and analysts in multiple locales to be representative and statistically valid, and keep to an absolute minimum its intrusion on the psychoanalytic process itself. Despite the latter condition, it must employ independent measures of patient and analyst characteristics, clinical change in the patient, the nature of the psychoanalytic process in each case, and the ultimate outcome at the end of treatment and years later. Most of these assessments, particularly those dealing with psychoanalytic process, call for further elaboration of research tools.
The question of “controls” and comparison groups will have to be addressed, although the idea of a “double blind” study seems both daunting and clinically absurd. Following the recommendations of the American, the study would be implemented independently through academic centers or a research organization.
Despite pressure from some highly respected leaders in psychiatry to take part in a massive study of all psychotherapies, the Task Force feels that it will be difficult enough to do a good study of psychoanalysis alone, which is relatively more homogeneous in many respects. Perhaps the design of a psychoanalytic study can be such that it would facilitate parallel studies of other kinds of psychotherapy that would allow for comparison.
We shall probably have to accept some conditions of the study that impinge on the psychoanalytic process. Accountability is involved, and we are challenged to develop a creative and clinically workable response rather than to throw up our hands in horror.
Besides the design of a definitive efficacy study, two major problems present themselves. One is funding, probably on the order of hundreds of thousands of dollars. The other is the willingness of experienced, practicing psychoanalysts across the country to commit the time, energy, and openness to scrutiny that will inevitably be necessary.
A valid efficacy study is part of the price we must pay to maintain our proper place in scientific medicine and psychology and to make psychoanalysis available to those who need it in future generations. When the time comes to do what must be done, will seasoned psychoanalysts across the nation be prepared to step forward?