The following is the text of Dr. Clemens's introductory remarks before the Mental Health Working Group of the White House Task Force on Health on April 23, 1993.
Good afternoon. I am Norman A. Clemens, M.D. We appreciate the opportunity to speak with you about the place of intensive psychotherapy and psychoanalysis in the health care system of the future.
The treatment of pervasive and persistent Axis I and Axis II disorders generally requires long-term psychotherapy. One can divide long-term psychotherapy into three categories: (1) Supportive or maintenance psychotherapy benefits people with chronic illness in which fundamental recovery is unlikely but can be considerably enhanced and relapse avoided. (2) Intensive psychotherapy is for those patients in whom fundamental changes can be accomplished while meeting one to three times a week. It is sometimes the only way to manage patients with severe personality disorders complicated by affective disorders, anxiety disorders, or eating disorders to forestall self-destructive behavior or hospitalization. (3) Psychoanalysis is for those patients who have serious and pervasive psychopathology but for whom more significant changes in the mental condition causing the psychopathology are both necessary and possible. This is a very highly studied and relatively standardized treatment method conducted four or five times a week. It is a tertiary case service, usually done when less intensive treatment has either failed or is likely to fail.
We cross a threshold at a certain number of sessions a week, a number that varies a bit from patient to patient, when a whole new world of treatment opens up.
Psychoanalytically based treatments help the patient understand and master parts of mental life that were previously beyond awareness. Generally these result from memories of early childhood experiences and unconscious persistence of the young child's efforts to cope with them. These primitive thought patterns cause lifelong psychopathology and serious dysfunction. The patient has to live out the problematic emotions and self-protective mental mechanisms within the relationship with the therapist in order to understand and modify them. This experience requires a safe environment in which the patient is confident that he/she will not be rejected and the treatment will not be interrupted, so that very painful issues, once confronted, can be resolved.
Unconscious issues cannot be approached in a predetermined, directive manner. Discovery requires the establishment of a unique setting in which the patient is and feels completely safe to allow innermost thoughts and feelings to emerge uncensored. As the hidden difficulties behind the manifest psychopathology become available, changes take place through an intense process in which analyst and patient work together.
The insight-oriented treatments are designed to lead ultimately to a planned termination based on definitive and lasting change. Treatment may go on for several years, even five or six years, but it comes to a conclusion. Thus, it must be distinguished from maintenance treatments that may support functioning for the rest of a patient's life.
The relationship with the therapist is extremely important, and its effects remain with patients as long as they live. On several occasions I have been called by patients who wanted to see me, maybe just once, as much as thirty years after completion of a successful treatment, to deal with their reactions to a terminal illness.
The scientific data base of psychoanalysis is a highly developed application of the case study method. Consensus develops through an extensive dialogue in a large, worldwide literature that began a century ago and continues to evolve with new discoveries and concepts. In-depth study of the individual human psyche does not lend itself to double-blind comparisons or statistical analysis. Nonetheless, we are applying a scientific method that has been enormously fruitful.
Psychoanalysis is included as a treatment modality appropriate for eating disorders and for major depression in the newly published American Psychiatric Association practice guidelines. Medical psychoanalysis has is own CPT code (90845) and was found to have somewhat higher work relative value in the Hsiao RBRVS study. Due to lower practice expense and malpractice costs, its Medicare fee is about 95% of that for 90844, individual medical psychotherapy.
We are speaking on behalf of a group of patients who find it very difficult to “go public” with their illness and the benefits of treatment. As one benefits manager put it, mental illness coverage is a “low-visibility takeaway” for that reason; people are afraid to protest. Our patients have immense distress and significant functional impairments, and so they resent being characterized as the “worried well” or considered less deserving of treatments than patients considered to be “severely mentally ill.” Because of potential functional gains, it is in employers' best interest to provide treatment for these people.
The benefits of psychoanalysis and psychotherapy extend far beyond the patient. The “ripple effect” on marital partners, children, coworkers, and the community can be extensive. I hope that the report I sent you from the Cleveland Center for Research in Child Development will convince you of that. Psychoanalytic knowledge has deeply enriched the training of general physicians, a contribution to good patient care in which Case Western Reserve was a pioneer. Just one example is the change that allowed parents to be with their children during hospitalizations.
Psychotherapy, based on psychoanalytic understanding of the person, can reduce the dosage and duration of use of psychotropic medication, or enhance compliance where continued medication is essential. Freud predicted that eventually neurophysiological data would confirm the effect of psychotherapy on the altered physiology associated with psychopathology; if so, the artificial dichotomy between somatic and psychological treatments would be erased.
The testimony that will follow will deal with a number of misconceptions about intensive outpatient psychotherapy. What we hope to demonstrate is the following:
Our patients are significantly ill and do not come to treatment for growth enhancement or self-actualization reasons.
The efficacy of psychoanalysis has been studied, and completed psychoanalysis has a clear advantage.
Intensive psychotherapy does not break the bank, and reasonable accountability is possible.
Intensive psychotherapy and psychoanalysis are extremely important in the whole system of care for children.
Women are especially vulnerable when treatment of mental illness is curtailed.
Overly aggressive managed care destroys the essential conditions for intensive psychotherapy and psychoanalysis.
Psychoanalysts have extensive training after their usual professional education. Their number is limited and it takes many years to train new analysts.
The number of patients who can be accommodated is small relative to the universe of mental illness, so that great care goes into selection of patients for psychoanalysis. This is a tertiary care service that may be lifesaving for those who meet the criteria.
The influence of psychoanalysis enriches the treatment of all mental illness and is vital to psychiatry and allied professions.
We join the Mental Health Liaison Group in advocating for full and nondiscriminatory coverage of treatment of mental illness on the same basis as other medical disorders.
Today we can only present abbreviated case histories and dry reports of studies and statistics. We hope that behind this you can get some feeling of the power and human engagement of psychoanalytic work—the searching, the pain, the discovery, the triumph that have led not only our patients but also the analyst members of this panel to do whatever it takes to make it happen.