The following letter was sent to Sheila M. Grant, Utilization Management Case Manager with Green Spring of Maryland. A member of the Baltimore-Washington Society for Psychoanalysis sent us a copy of a recent review of his psychoanalytic case by psychoanalysts, one in Chicago and one in Maine, that resulted in a denial of coverage by Green Spring and Blue Cross/Blue Shield of Maryland for the patient's ongoing psychoanalysis. A copy of the relevant portion of the report is attached. We wish to take exception to comments in the report of those analysts, and indicate that they do not represent the majority view of the American psychoanalytic community, but rather, they are articulating a view held by only a very small number of psychoanalysts. To accept the conclusions of the reviewers would be like taking statements of Thomas Szasz, M.D., as representing the views of American psychiatry.
Symptomatic improvement in psychoanalysis during the first 2–3 years of psychoanalysis is not unusual, and is related to the development of transference phenomena and the focusing onto the analyst of conflicts previously expressed as symptoms. These conflicts then need to be sufficiently analyzed, so that the patient will be truly free of the symptoms after the analysis ends. To accept symptomatic improvement as a sign that the analysis is completed, and that the improvement will be sustained after a premature ending of the analysis, is dangerously ill-advised. When psychoanalysis is approved initially, this should imply that there will be financial commitment by the third party to its appropriate conclusion. Not to do so is akin to paying a surgeon to open an abdomen and close the wound without removing the diseased tissue. Many studies show that analysis is one of the most powerful and effective treatments for suitable patients. We therefore strongly disagree with the reviewing analysts' comments: “Perhaps there was a confusion on the part of the patient and psychoanalyst about the concept of medical necessity. Medical necessity deals with alleviation of symptoms, and perhaps they are feeling that the total resolution of intrapsychic conflict is a point that would indicate medical necessity. Such is not the case.” Psychoanalysis, unlike other therapies, has as its goal the resolution of intrapsychic conflict causing the symptoms. The symptomatic improvement, although important, does not necessarily indicate the conflicts are adequately understood and worked through.
William C. Wimmer, M.D., President, Baltimore-Washington Society for Psychoanalysis; Manuel Romand, M.D., President, Washington Psychoanalytic Society; James H. Hutchinson, M.D., President, Washington Psychiatric Society; Judith S. Schachter, M.D., President, American Psychoanalytic Association; Lawrence S. Chalfin, M.D., Chairman, Board on Professional Standards, American Psychoanalytic Association.