As a Trustee of the American Psychiatric Association (APA), I was asked by President Herbert Sacks to represent the APA at the Executive Council of the American Psychoanalytic Association on December 18, 1997. A crowded agenda prevented me from delivering the prepared remarks that I had been asked to make. Instead, I have been invited to share them with The Americans members in TAP.
The two organizations that represent my professional identity have a great deal in common. Both The American and the APA face an adverse and hostile climate for high-quality, ethical practice. Both decry an erosion of respect for the individual human being in the tidal wave of global, corporate entities; information technology; and mean-spirited cost-cutting for human services. Both are concerned about recruiting young people into our professions. Both face the “graying” of their membership and membership attrition as dues become burdensome to falling incomes. Both struggle to preserve professional identity and values, and both advocate for access to effective, confidential, committed patient care.
I wish to comment on three issues of great concern to both the American and the APA: privacy, psychotherapy by psychiatrists, and practice guidelines.
The privacy and confidentiality of mental health services are threatened today as never before. Not only does managed care require that extensive data on patients be communicated to faceless strangers for its intrusive and disruptive reviews; in addition, the drive to create huge, universal medical databases pits the corporate computer giants and health systems developers against the individual patient and his or her therapist.
The APA has worked closely with the government relations consultant of The American and the Coalition for Patient Rights to combat these trends. For the APA it has a very high priority. The APA submitted a brief to the Supreme Court in Jaffee vs. Redmond defending the confidentiality of psychotherapy. The APA protested vigorously against U.S. Secretary of Health and Human Services Donna Shalala's position that law enforcement agencies should have access to patient records without patient permission or due process. The APA supports the Leahy bill, which is the only reasonable confidentiality bill appearing in this session of Congress.
Richard Harding, a recent Speaker of the APA Assembly, was appointed to the APAs National Committee on Health and Vital Statistics working group on confidentiality, where he championed the cause. The APA played a major role in obtaining a clear acknowledgment by the Health Care Financing Administration of the right of the Medicare patient to contract privately for reasons of confidentiality.
The APA is now working in support of the Kyl-Archer bills to correct the excesses of the Balanced Billing Act, which requires a physician who chooses to contract privately to opt out of billing for any Medicare patients for two years. Two principles very clearly govern APA policy in the arena of new information systems: The patient must have control over who gets the information, and the physician or therapist must have the right to maintain private notes outside of any medical databank.
There is an alarming trend, fostered by both managed care and a trend to diagnose biological causes for all symptoms, to limit psychiatrists to providing only evaluation services and medication management. Psychiatric training is beginning to echo this trend and to place diminished emphasis on psychotherapy skills, especially in-depth psychotherapy.
The APA has established a Commission on Psychotherapy by Psychiatrists, which Glen Gabbard and I co-chair, to work at countering these trends. Other members of The American — Allan Tasman, Barton Blinder, Marcia Goin, Jerry Kay, Susan Lazar, and Will Sledge — and one of The American's Fellows, Eva Szigethy, a resident in child psychiatry, are also on the commission. Leading clinicians and researchers from cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), family systems, and group therapy make up the remainder. The commission has a high profile in the APA and liaisons with allied organizations including The American, the American Academy of Psychoanalysis, and the American Association of Child and Adolescent Psychiatry, and with the Canadian Psychiatric Association.
Part of our task is to gather information that will sway decisionmakers. Members of the commission have presented reviews of the
literature on efficacy and cost-effectiveness of psychotherapy in several peer-reviewed publications and in a standing-room-only forum at the APAs annual meeting last May. This year we shall present a forum on the neurobiological correlates of psychotherapy.
Two major initiatives to upgrade psychotherapy training for psychiatric residents are also in the works. The commission's work has been heartening to the many residents involved in APA leadership. They have been highly concerned about deteriorating psychotherapy training, the availability of psychotherapy for themselves, and subsequent practice opportunities.
The practice guideline for panic disorder was approved by the APA Board of Trustees in December 1997. Earlier drafts had aroused horror among the psychoanalysts who reviewed them. Sheila Hafter Gray, Barbara Rosenfeld, Barbara Milrod, Sherwyn Woods, Marcia Goin, and I submitted extensive comments about the exclusive focus on CBT alone or medications alone as first-line treatments for panic disorder. (Please note, however, that this guideline breaks ground in presenting research evidence that psychotherapy alone is as effective as medication.) We also objected strongly to the highly skewed section on children and adolescents.
The guideline work group responded to our objections and incorporated much of our suggested language, which created an important place for psychodynamic psychotherapy in the panic disorder guideline—especially for people with personality disorders, so-called co-morbid conditions, or failure to respond to other interventions. Marcia Goin and I pushed for changes
Norman A. Clemens, M.D., is Area IV Trustee and past Speaker of the Assembly of the American Psychiatric Association. He is a Fellow of the Board on Professional Standards and past chair of The American's Committee on Government Relations and Insurance. He is a clinical professor of psychiatry at Case Western Reserve University in Cleveland.
right up to the day before the guideline was adopted, to the point that the research people threatened to withdraw from the project.
The final product still fails to acknowledge the widespread use of psychodynamic psychotherapy in panic disorder, and it is woefully inadequate regarding children. But it will not create adverse conditions for doing what we know works for patients, and it may even be helpful to us at times. I know some of you have heard dire things about this guideline, and I urge you to read carefully the final product in the May issue of the American Journal of Psychiatry before passing judgment.
The next guideline important to us will be on treating borderline personality disorder. Prominent psychoanalytic researchers will have major roles in that project, in contrast to the panic disorder guideline project. The experience of working on the panic disorder guideline made me acutely aware that without well-constructed efficacy and effectiveness studies on specific diagnostic entities, we are fighting a rear-guard action.
It is a basic principle of the APA practice guidelines project that broad clinical consensus must play a major part in treatment recommendations, especially in the absence of research data. It is also clear that the conditions of rigorous efficacy research do not correspond to real life, so research conclusions must be balanced with what experienced clinicians know from working with patients. The problem is in determining what truly is clinical consensus.
Psychoanalytic therapies will not play an important part in future guidelines unless psychoanalysts intensify their efforts now to study their treatment systematically. In the present world of accountability and demand for evidence, nothing less will do. We may not like the narrow focus on symptoms, but only evidence will help us overcome that point of view. Polemics will not help our cause. It requires reasoned, evidence-based advocacy for treatments that look beyond symptoms to the complex mental life of the individual.
The psychodynamic psychotherapy that fills a large part of the working life of our members has been a poor stepchild of organized psychoanalysis. This has led to a scarcity both of research data on psychodynamic psychotherapy and of advocacy by psychoanalysts to balance the extensive research basis of CBT, IPT, and medications. We must find better ways to validate the case study method to convey the power of what we do, not just for symptoms but for the human being who comes to us for help. We must also meet the research establishment on its own ground by supporting the dedicated psychoanalytic researchers in our midst. This has ramifications far beyond practice guidelines, for the future of psychiatric training and the profession.