Rosenblitt: As chair of BOPS, what do you see as the single most significant issue facing psychoanalysis today?
Chalfin: Practice is the most serious concern of our members at this point in our history. Everywhere we see a significant dropping-off in analytic caseloads. This has occasioned widespread anxiety. Insufficient immersion in psychoanalysis must negatively affect one's professional self-esteem and identity, one's development as a psychoanalyst, wishes for professional advancement, and of course one's livelihood. This limited opportunity for practice is eroding our morale and creating among many of us serious concerns about our personal, professional, and organizational futures.
Rosenblitt: The Board's primary responsibility is the maintenance of standards of education. How do you explain this new emphasis on practice issues?
Chalfin. Practice issues impact on the responsibilities of the Board in every area. Our standards cannot be maintained without adequate practice and clinical immersion. In the past, when practices were robust, the Board did not need to address itself to practice. Now, talented prospective candidates hesitate to enter our institutes. Those who do enter often have difficulty achieving the level of clinical immersion necessary for the optimal integration of learning under our tripartite system of education. Graduates may not progress toward certification. Faculty have difficulty maintaining the level of immersion and pace of development so necessary if they are to be effective clinical teachers and achieve training analyst status. For all these reasons, institutes are in a struggle for survival as effective educational centers for psychoanalysis.
Rosenblitt: The current climate in training programs and within societies presents many obstacles for those who may be motivated toward pursuing psychoanalysis as a profession. Do you agree?
Chalfin: Because of the diminishing opportunities for practice, and the concomitant rise of biological and short-term treatment approaches to patients, the profession of psychoanalysis—and even the teaching of psychodynamic points of view—is increasingly denigrated in psychiatric residencies and doctoral programs in psychology. Further, the use of biological treatments and crisis intervention is increasingly supported by government insurance programs and by managed care, with its emphasis on bottom-line and short-term “medically necessary” treatments. It will require a major undertaking to mobilize ourselves against this national quest for short-term, impersonal, inexpensive symptomatic relief and to demonstrate that the immediate-gain principle leads to serious long-term consequences for patients and for society.
Rosenblitt: Can you address further the role that managed care plays in this change? Most analysts are seriously concerned about the inroads it is making on national attitudes toward mental health care, specifically intensive treatments.
Chalfin: The impact of managed care on psychoanalytic practice and education is a complicated one, with both overt and insidious deleterious effects. Managed care is imposing its profit-oriented approach on people's values and expectations about health and illness. The long-term treatment and chronic care that are required for many physical and mental illnesses are now denigrated as “medically unnecessary.” Given the rapidly increasing dominance of the managed care model, the need to solve our practice issues becomes even more urgent. Our members require an outside-the-system practice base sufficient to avoid too great a dependence on insurance and managed care support. Even the rare third-party payer that still supports some sort of intensive treatment will inevitably impose its definition of such treatment on us, as has been the experience in Germany. Too great a financial dependence on these payers will increase our difficulty in resisting inappropriate definitions of psychoanalysis. Treatment definitions, recommendations, and decisions are increasingly becoming three-party interactions rather than strictly analyst-patient decisions. Treatment and educational difficulties are bound to follow.
Rosenblitt: Can you clarify what you mean by three-party definitions and the problems they will create?
Chalfin: A recent managed care situation illustrates this very well. I quote from the decision by a managed care company review panel to deny coverage for an ongoing psychoanalysis: “At any rate, the above concerns that we would have about the psychoanalytic treatment are in a sense besides the point. The point from a review aspect is that this is a patient who has made significant and dramatic improvement in the target symptoms he entered treatment for. At this time, with such a dramatic improvement in his clinical picture, we can see no medical necessity for treatment to continue on an ongoing basis and in an open-ended way, particularly at the frequency being requested. 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.”
This company's definitional basis for medical necessity is accepted throughout the managed care and DSM-IV based worlds. In such a climate we have transcended our recent concerns about managed care “contamination” of psychoanalytic treatment. There the question was, Can it be managed as grist for the analytic mill? But here we have entered the realm in which the psychoanalytic frame, the patient-analyst relationship, and the treatment goals and ethical and human values of psychoanalysis are being subjected to a radical redefinition, one that undermines the integrity of the treatment, our professional identity, and our commitment to the best interests of the patient. Bending our standards to accommodate such a redefinition would be a futile and misplaced effort to conform to a view of psychoanalysis that does not recognize what we understand to be the conditions we consider essential for its practice.
Rosenblitt: You spoke of an impact on analytic education as well. Can you elaborate?
Chalfin: There are some immediate and vexing dilemmas for psychoanalytic education. Candidates may be forced to undertake supervised analysis of a case that is conducted according to this three-party model. This undoubtedly is already happening. How should we regard such training experiences? Are cases conducted using such a model appropriate as control cases under all circumstances? Almost all of us have at one time or another conducted analyses that were covered by insurance; we have made a judgment that the reporting requirements do not interfere with the ethical conduct of the treatment. It may be helpful for the Board to offer guidelines for responsible third-party involvement, particularly as the current revision of standards is being undertaken. After all, the requirement of three control cases is more than just a numerical standard. The three-case standard is meant to provide a meaningful introduction to the issues of psychoanalyses conducted under the range of psychoanalytic conditions that do not distort the basic frame of treatment.
In a more general vein, we can no longer rely on the prepsychoanalytic training of our candidates to give them an ease and competence in
intense, long-term professional relationships. As clinical training programs have more and more come to depend on insurance reimbursement for their financial survival, educational curricula are being bent accordingly. These changes in curricula diminish opportunities for students to learn about psychoanalysis and remove opportunities for them to gain supervised experience in the practice of psychotherapy. Tomorrow's analyst will have relatively less psychotherapy experience and will often think of whatever works therapeutically as being psychoanalysis. The complex philosophical and practical issues involved in the distinction between analysis and therapy will have to occupy more of our educational attention if analysis is not to degenerate into just another, none-too-well defined form of treatment. Powerful interests, ranging from profit-seeking insurance companies, through professors of psychiatry who lack psychoanalytic education, to reformers who allow their wishes for a more fair world to obscure and diminish efforts required to modify neurotic suffering and behavior, now have a stake in persuading the public that we are neither useful nor trustworthy. The quality of education in each of our institutes, and the integrity of our graduates, are of the utmost practical, as well as ethical, concern to us all. The maintenance of this quality allows us to be confident of the result, as the general public, over time, contrasts treatment by analysts educated by institutes of The American with treatment conducted by those who follow the current quest for the quick fix. The public will then understand why there is no safer bet in the mental health marketplace than choosing an analyst trained by The American.
Rosenblitt: And, returning to the overriding issue, how are we to achieve the private practice base so necessary to our survival? What can The American do to help?
Chalfin: This is an issue that affects The American at all levels, beginning with analytic education. Essentially, I believe that we must advocate for psychoanalytic treatment in a continuous, professionally conducted, national campaign to educate the public. In the 1950s and in subsequent decades, psychoanalysis was part of the national consciousness. This is no longer so. It has been a long road to this change. In part, our early enthusiasms about our efficacy in a wide range of situations led to disillusionment. Our professional knowledge and experience has grown enormously since then. Our understanding of psychopathology and mental functioning in general has expanded considerably, as has our understanding of the problems and opportunities in psychoanalytic methodology.
Rosenblitt: Is it then your view that psychoanalysts must speak again with our own special voice?
Chalfin: Yes. Most psychoanalysts belong to psychiatric, psychological, and social work groups whose support for psychoanalysis as a form of intensive psychotherapy is of obvious importance. While welcoming the support of such groups, we as analysts carry the responsibility for maintaining professional and public awareness of what psychoanalysis in fact is. Recent changes in the training of all groups of mental health professionals mean that tomorrow's mental health professional may not seem the most natural choice for patients wanting to deal with personal problems. A strong public presence by psychoanalysts making clear what is different about psychoanalysts—our intense and extensive training, our emphasis on informed listening, our emphasis on the pursuit of truth in a private, confidential setting—will bring us patients who would otherwise wind up in the hands of the less well trained, who might seek help outside the mental health system, or who might simply succumb to despair.
Rosenblitt: How can we translate these gains into an effective public education effort?
Chalfin: We need to convey to the public the essentials of our treatment, what it is for, and how it is different from other psychotherapies. We have to be clear about what we can and cannot offer. We have to explain the necessary conditions for our work. We have to explain how managed care approaches are antithetical to these conditions. One illustration of how effective we can be is provided by the recent announcement by the Coalition for Patients' Rights of its success in ensuring the right to private contracting of services and the right to confidentiality for Medicare patients. Another illustration is the work of Drew Clemens in clarifying the indications for psychoanalysis with a managed care provider. We also need to explain the role of The American and its institutes, and of the Board on Professional Standards, in maintaining rigorous and ethically responsible standards of education and practice designed to protect the public. Our low-cost clinics, which make quality psychoanalysis under experienced supervision available to anyone who needs it, must be advertised. We need to go beyond defensive responses to attacks by critics such as Frederick Crews, who force us to argue on currently irrelevant grounds, and beyond efforts to convince government and insurance carriers to include full psychoanalytic coverage in their plans, a quixotic effort in any event. We need to become aggressively visible, proactive advocates for psychoanalysis.
Rosenblitt: What mechanisms are available for achieving this?
Chalfin: In these times, there are many ways to get the message out. We have a strong message that has already been put forth in our recently revised About Psychoanalysis brochure. However, opportunities become realities through professional leadership that provides the necessary knowledge, time, creativity, and organization. This major effort requires prompt action. For me and for increasing numbers of analysts I speak with, the future of our profession may well depend on how bold we are in the arena of public education.