In his technical “recommendations” on the beginning and maintenance of psychoanalytic treatment, Freud could hardly have anticipated the profound influence insurance coverage would come to have on the analytic process. In emphasizing the exclusion of all other parties from the relationship between analyst and patient, he clearly had the patient's relatives foremost in mind. “Psychoanalytic treatment,” he wrote in the Introductory Lectures, “may be compared with a surgical operation and may similarly claim to be carried out under arrangements that will be the most favorable for its success. You know the precautionary measures adopted by a surgeon: a suitable room, good lighting, assistants, exclusion of the patient's relatives, and so on. Ask yourselves now how many of these operations would turn out successfully if they had to take place in the presence of all the members of the patient's family, who would stick their noses into the field of the operation and exclaim aloud at every incision. In psychoanalytic treatments the intervention of relatives is a positive danger and a danger one does not know how to meet.”
But what would Freud have said were the intervenor a third-party payer? What does it mean to have an insurance reviewer walk in and out of the “psychoanalytic field,” inquiring into and commenting on the unfolding events while the operation is in progress?
The technical rules for beginning an analysis stress proper preparation for a struggle that will play itself out in the course of treatment. Freud recognized that the forces of the mind, which under the sway of the ego have achieved an equilibrium, will strive to maintain that status quo in the face of uncovering techniques that use the transference to elucidate resistance and warded-off ideation. Because ideally the rules facilitate a process emphasizing the patient's potential for autonomy and insight, when third-party payers are involved in an analysis it must be structured from the very beginning to take this highly significant factor into account.
In courses on technique, candidates must be told of the need to be clear and matter-of-fact in setting up the “contract,” what might more comfortably be referred to as the “opening agreements” or “opening arrangements.” They may be told facetiously that “this is probably the last time you will be talking to a sane patient!”—a bit of pedagogic hyperbole meant to suggest how the opening arrangements, seemingly entered into freely and rationally, will soon be drawn into an inexorable struggle. What the novice analyst takes as mutually agreed on at the beginning of treatment can undergo every conceivable distortion as it is played out in the vicissitudes of the transference.
Loose ends in the arrangements, often due to uncertainty, inconsistency, or countertransference conflicts on the part of the analyst, allow few points of reference once the distortions begin. Soon the analyst may, wittingly or not, be pushed into an authoritarian role in the attempt to set things straight. Arrangements may be ambiguous or inadequately delineated regarding fees, the need for frequent and regular sessions to facilitate momentum and intensity, missed sessions (a subject that holds the potential for moral judgments of the patient's behavior), and frequent or unpredictable absences by the analyst on short notice. Such circumstances greatly increase the likelihood of masochistic defenses in the patient. Defensive compliance or defiance becomes the order of the day, and analysis of what in a more neutral setting would bubble up spontaneously from within is compromised or lost.
For better or worse, and much too often the latter, insurance is now a common factor to be dealt with, particularly in communities such as Washington and Baltimore, where government and private plans abound, often of the “managed care” variety. In such programs the patient has signed agreements authorizing the insurer to request periodic written reports from the “provider” analyst, in order that the treatment be certified as indicated, and documented as progressing satisfactorily. While the putative rationale for this measure is the maintenance of quality control, too often it is carried out by the insurer in a manner that suggests that any means possible will be used to deny or delay the claim. On occasion, recommendations are made by reviewers that would coerce the use of a briefer form of psychotherapy or a symptomatic approach using psychotropic drugs. In many instances these reviewers, even at the higher levels of appeal, are not analysts.
Under these circumstances, any interaction by the analyst with the insurer will involve transference manifestations and be drawn into the analytic struggle. Transference splits are a real danger. The third-party payer can assume, in the patient's and even the analyst's mind, the role of an intrusive parent who demands to know what is going on, holds the pursestrings, and is at best ambivalent about the analysis. And of course it need hardly be remarked that the insurance company lacks entirely the parental concern that might lead it to support the treatment even when dubious about the recommendation, or uncertain about therapeutic progress. Rarely is the choice of analysis by an intelligent and informed consumer acknowledged as relevant by insurers, who invariably deal only with the analyst regarding a claim.
In 1986 the American Psychoanalytic Association published a pamphlet entitled “Reporting Information for Claims Review of Psychoanalysis.” Although well-intentioned, this widely distributed document has been used by insurance companies to justify their demands for increasingly detailed information about analyses. The contention is that The American has placed its imprimatur on the methodical reporting and specific description of analytic events, in detail that would do a clinical conference proud. The pamphlet recommends and details the initial reporting of such items as diagnosis, symptoms, functional impairments, relevant history, details of prior treatment, mental status, diagnostic studies, assessment of familial and social relationships, evidence of analyzability, treatment plan, goals of treatment (short-, intermediate-, and long-range), estimated duration of treatment, and criteria for termination. The following advice is given for reporting the progress of the analysis: “Note changes in symptoms, external life adjustment, object relationships, affect modulation, capacity to tolerate frustration and anxiety. Indicate whether the short- and intermediate-range clinical goals have been achieved. Describe the patient's use of the psychoanalytic method—have you altered your treatment approach or treatment goals? (if you have explain)—and estimated duration of the treatment.”
It is interesting to speculate what Freud would have to say about these recommendations. He recognized early on the problem of trying to formulate a case before treatment begins, and of estimating progress, particularly early in an analysis. In 1912 he wrote, “It is not a good thing to work on a case scientifically while treatment is still proceeding—to piece together its structure, to try to foretell its further progress, and to get a picture from time to time of the current state of affairs, as scientific interest [or the insurer's interest] would demand. Cases which are devoted from the first to scientific purposes and are treated accordingly suffer in their outcome; while the most successful cases are those in which one proceeds, as it were, without any purpose in view, allows oneself to be taken by surprise by any new turn in them, and always meets them with an open mind, free from any presuppositions.”
Not a word is uttered, in The American's pamphlet on claims review, of the possible effects of that practice on an analysis, particularly the transference. No mention is made of the necessity of
sharing with the patient all information given insurers, or of the fact that this may occasion a defensive intellectualization and put the ego on guard against revealing anything in repression that is touched on by the analyst's formulations and predictions. No technique is suggested for maintaining the viability of the analysis in the face of this intrusiveness. There is a significant potential here to exacerbate the patient's resistance to working out a wide range of conflicts and achieving greater autonomy. Nothing in the pamphlet lets the insurance reviewer understand the dangers inherent in the reporting procedure, particularly when it is carried out inappropriately and without concern for the nature of analysis. If there is any true interest in quality control, rather than just cost control, these risks to treatment should be described along with the recommended reporting procedures.
To prepare for the parameter of dealing with third-party payers and institutional intrusion, rules must be set up whereby the analyst in no way diminishes the autonomy of a patient who attempts to obtain insurance benefits paid for in good faith. If insurance will be involved in the payment of fees, it should be made clear to the patient that all financial arrangements and payments are transacted between patient and analyst. To ensure that transference splits over money issues are avoided, the analyst should insist, to the extent that it is possible, that insurance payments be made directly by the company to the patient. It should be emphasized to the patient that no communication will take place with the insurance company except through the patient, who is the one holding the contract with the third-party payer. This means that all necessary paperwork should be placed in the hands of the patient, who may deal with it in any way that seems fit. The patient should eventually be encouraged to participate in the formulation of any material that might minimally be essential to processing the claims. All calls by the insurance carrier should be reported to the patient, who should handle all responses. Where replies by the analyst are insisted on by the insurer, the request should be in writing, the letter or form shared with the patient, and a copy of the written response given to the patient.
By outlining this general approach in making the opening arrangements, the analyst prepares the stage for keeping to interpretation when regressive pressures by the patient threaten to draw the analyst into active struggle with a demanding and possibly critical insurer. A great many hidden aggressive agendas can be played out in the insurance scenario if the analyst is pushed into playing the role of protector, successful or otherwise, in the guise of exercising “common sense” professional functions as an insurance “facilitator.” Care must be taken that masochistic submission to insurance demands is not hidden and that resistance against the disclosure of such fantasies toward the analyst are not lost in the insurance interaction. Suffice it to say, countertransference pressures are always present in dealings with outside evaluators, who may be in a position to enunciate the most outrageous formulations about an analysis. Various prices are paid for the benefits of insurance; in some cases, patients come autonomously to the conclusion that they cannot avail themselves of these benefits while maintaining the confidentiality requisite to an analysis.
A somewhat happier result is seen in the case of a female patient who suffered mightily at the hands of her insurers. They demanded detailed progress reports, delayed their responses, and finally withheld approved reimbursements for months. This familiar action of the insurer fed into every punishing fantasy the patient had over fears of being too entitled, too assertive, too capable. Through dedicated work on the part of both patient and analyst, transference paradigms were addressed in spite of stubborn and ingenious resistance, and sadomasochistic conflicts were steadily worked through. Gradually the patient began to address her insurance picture in a forceful and realistic fashion. On one occasion later in her analysis, she described how she managed to reach a vice president of the company after her claim had been mishandled and payment long delayed. When she identified herself to this impatient and officious executive as a patient in analysis who felt her treatment had been compromised by the company's mishandling of her claim, he indignantly retorted, “We have lots of really sick patients who have had to wait for their claims to be taken care of, and they will have to come first!” The patient coolly responded, “Who are you to define my suffering? I expect all my delayed payments to be sent out now!” Clearly the man did not expect such an answer from a usually defensive “mental case.” Instead, he found himself facing a patient who, having worked out a great deal, was now free to press her claim to what previously had been experienced as a forbidden and incestuously contaminated entitlement. Against all odds in this all-too-typical “insurance game,” she protected her analysis, saw it as legitimate, and kept it going despite her limited economic resources.
How long or in what form intensive claims review and managed care will continue is anybody's guess. The high overhead of managed care may make it impracticable as regards whatever coverage will be available for psychoanalytic treatment. It may be wishful thinking to believe that the pressures of third-party intrusion, in its various forms, can be ignored, if psychoanalysis is to be acknowledged and included in some form of mental health insurance program. Meanwhile, it is the task of analysts, whose technical ingenuity will be severely tested, to define the limits within which psychoanalysis can maintain its clinical integrity in the face of this intrusion.