American Psychoanalytic Association Practice Bulletin 1: Informed Consent to Review

The proliferation of managed care systems has intensified concern about the effect of the psychoanalyst's interaction with third parties on the therapeutic alliance and ultimately on the outcome of a psychoanalysis. The Committee on Peer Review collected anecdotal evidence that supports the notion that reviewed cases may end prematurely or may suffer major distortions of the therapeutic alliance (Gray, 1992). We concluded that the consent forms that third parties or their agents ask our patients to sign do not adequately explain the risks to psychoanalysis posed by the review process and that consent so obtained is considerably less than informed.

External quality assurance and managed care reviews are not isolated matters. They are components of the actuality in which psychoanalysts and their patients live and in which psychoanalytic practice takes place. We view third-party funding of psychoanalysis by employers, and therefore by insurance, as one example of third-party funding. Others are spouses, parents, other relatives, or friends. Each method of funding has its particular risks and benefits. Any contact between the psychoanalyst and a third party must be viewed in this context. It must be subjected to scrutiny from many viewpoints, including its impact on the clinical psychoanalytic situation and its specific meaning or meanings to the patient.

Each clinician will have developed and will use a procedure to offer prospective patients an opportunity to get information on which they may base a decision to accept or to decline psychoanalysis. This is part of the process of initiating psychoanalytic treatment, which will be addressed in the Committee on Peer Review's draft practice parameters. This process should contain discussions of the psychoanalyst's position in respect of reporting information to third parties, and of the patient's needs for such reports.

We acknowledge that some clinicians have an authoritative, prescriptive approach, while others tend to foster patients arriving independently at the decision to undertake psychoanalysis. We state no preference for one style over the other. We do believe that when complex interactions with third parties are or may become part of the treatment situation, it is advisable that before psychoanalysis begins both patient and psychoanalyst understand and undertake to abide by the stated preferences of the other in respect of participation in the review process.

If patient and analyst agree to submit psychoanalytic individual treatment plans or other reports to third parties, the appended form may be useful. This draft follows the format suggested by the District of Columbia Mental Health Information Act. We used it because that act is very restrictive of communication between clinicians and third parties. The Model Release is generic; it may be modified to conform to applicable laws in the jurisdiction in which the psychoanalyst practices.