With the publication of the “Psychoanalytic Clinical Assessment,” insert in this issue of TAP, an integrated set of seven Practice Bulletins, APsaA's psychoanalytic practice guidelines, is now available to serve, support, and protect the vitality of psychoanalytic practice and education in these challenging times. In the early years, as the Committee on Peer Review was developing guidelines for charting and external review of psychoanalysis, we realized that a comprehensive guideline on psychoanalytic clinical assessment would also be needed, and we began that effort in 1997. The committee's next project will be to publish the entire set of guidelines in a monograph.
Psychoanalysts have needed an integrated set of procedure-based practice guidelines because a psychoanalytic approach is often different from the usual approach followed by other mental health-care specialists. Psychoanalysts are few, while other types of mental health specialists compose the powerful majority that has, albeit reluctantly in many cases, accepted a shift in national and community standards of practice. That significant shift followed economic opportunities that increasingly require managed care approaches to assessment, treatment, charting, and review.
By the mid-1990s, most APsaA members had a clear understanding that the managed care approach usually sacrifices confidentiality to the degree that successful psychoanalytic treatment is not viable. Managed care conditions have progressively eroded patients' confidence that information they share in the treatment setting will be held strictly private. In an effort to protect their privacy, many patients censor what they say. Conditions for viable psychoanalysis require that patients can be reasonably confident to speak freely and candidly with their analysts, without realistic concern that what they say will be conveyed to outsiders.
Without APsaA's integrated set of psychoanalytic practice guidelines, psychoanalysts would have little organizational support for maintaining good psychoanalytic practice. This is especially the case when psychoanalytic practice is called into question because its procedures differ from the managed care-friendly practices that have been imposed upon the majority of mental health-care practitioners.
The development of our newest Practice Bulletin, “Psychoanalytic Clinical Assessment” has followed our model to create practice guidelines that integrate evidence-based and consensus-based practices. This allows us to codify and use the collective clinical experience of the membership as well as established and current research findings. The Committee on Peer Review is indebted to all societies, their representatives, and individual members who have assisted us in the drafting process over the years of liaison and consensus conferencing. Throughout the drafting process, they raised numerous key questions and suggestions that have served to make these practice guidelines clear, comprehensive, and fully representative of the membership's clinical experience.
Our approach to developing practice guidelines strives to be a direct democratic process. We present early drafts widely to all societies, so that all members have the opportunity to study and give feedback early and often in the drafting process. This approach requires a tremendous amount of time and patience. “Charting Psychoanalysis,” for example, went through 17 major drafts prior to publication. This is an approach that first and foremost supports our adherence to psychoanalytic principles. Rather than sort concretely through conflicting particulars with an aim to develop a middle ground compromise, we have used psychoanalytic principles as our guide to derive abstract concepts that embrace the particulars collectively. In the end, our approach minimizes the need to accept significant compromises of vital principles. Compromise is ultimately accepted only (1) in situations of serious polarization of opinion within the membership, or (2) in situations of daunting legal, technical, and practical challenge, after exhausting all available resources to find a solution that honors the principle ideally.
First and foremost, the guidelines recognize the primacy of analysts' clinical judgment. Each guideline states that the analyst will make the ultimate judgment regarding a particular clinical decision, intervention, or overall treatment plan on the basis of the clinical data presented by the patient and the diagnostic and treatment options available in the particular clinical setting. The documents contained in our Practice Bulletins are intended as guidelines. They are not intended as standards of care that might prescribe or restrict the clinical judgment of the analyst. The guidelines are intended to act as strong support for good psychoanalytic practice, particularly when the recognized procedures of psychoanalytic practice are questioned or come under some form of scrutiny by outside parties.
Here are several examples of how each guideline seeks to accomplish this supportive task from a different perspective, and how the set of guidelines together represents an integration of intersecting conceptualizations.
“Charting Psychoanalysis” is based on the notion that psychoanalysis is a unitary therapeutic procedure that does not require session-by-session progress notes, just as a surgical operation does not require intra-operative notes. This practice guideline also defines
Robert R. Cummings, M.D., Ph.D., is chair of APsaA's Committee on Peer Review. He is a training and supervising analyst and has a private psychoanalytic practice in Laguna Hills, California.
process notes, working notes, and research notes as items separate from a patient's healthcare chart. It advises that items which are the personal property of the analyst be kept physically separate from the official chart. In 1996, a new guideline called “Charting Psychoanalysis, a Clarification” was created to remove any question and confirm that various substitutes for session-by-session progress notes, such as checklists and “negative charting” data sheets, fall within the guideline's definition of progress notes that are not necessary for, and may interfere with, good psychoanalytic treatment.
Many of our members have misunderstood the “Charting Psychoanalysis” guideline to say that analysts do not need to keep health-care charts for their patients. The guideline does not say that. The guideline defines psychoanalysis as a single procedure from start to finish, and it supports analysts who refrain from charting session-by-session progress notes. It does not provide any rationale for omitting the practice of maintaining an appropriate record of health care.
“Psychoanalytic Clinical Assessment” describes the nature and process of this important clinical procedure. It clarifies key differences between a psychoanalytic approach to aspects of this procedure compared with approaches by other mental health-care specialists. It also summarizes charting procedures derived from our “Charting Psychoanalysis” guideline as well as the other guidelines subsequently approved by our Executive Council.
The new “Psychoanalytic Clinical Assessment” guideline also defines what might constitute a complete private and confidential psychoanalytic health-care chart. The guideline states that such a record might contain the following items:
The appointment and fee-payment record of the treatment.
A note stating that a psychoanalytic clinical assessment process was conducted and led to a discussion with the patient of the advantages and disadvantages of various treatment options (specified) and to a mutual agreement upon a treatment plan (specified to include the frequency and length of sessions, an indication of whether the procedure is psychoanalysis or modified psychoanalytic treatment and reason for the choice of this treatment option, and a description of modifications or special features of the treatment plan).
Notes to document the occurrence and reason for any major changes in the treatment plan, forms of treatment, or recommendations by the analyst that the analyst considers to be outside the usual scope of psychoanalysis (e.g., prescription of medication, referral to a neurologist, etc.).
Any third party correspondence and a note documenting the patient's thoughtful consent for this correspondence.
A closing note at the end of treatment.
The “Psychoanalytic Clinical Assessment” guideline is useful if there is an inquiry about what this type of assessment procedure entails. It represents a comprehensive definition of the procedure. The existence of the guideline can help analysts who want to limit their charting procedures in order to be more effective in protecting patients' privacy and confidentiality. Before the existence of this guideline, there was little support for analysts who wanted to say less in their charts, in order to protect patients' privacy. Many felt it was necessary to document extensive clinical assessment information to indicate not only that a quality assessment was done, but also to define the general nature of a good psychoanalytic clinical assessment. Essentially, this had to be done with every case. Now, the guideline itself can serve to define and explain what the procedure is and how it is done. This significantly limits necessary charting. We do recommend that the treatment planning process be well documented, and include an indication that the assessment was done and when it was done.
Psychoanalysts have needed an integrated set of procedure-based practice guidelines because a psychoanalytic approach is often different from the usual approach followed by other mental health-care specialists.
A working knowledge of the practice guidelines can be useful when a patient raises issues of third-party payment during the assessment and treatment planning process. The guideline on “Informed Consent to Review” provides a model discussion of the likely risks and benefits if the patient decides to waive his or her right to keep clinical information private and directs that the information be sent to a third party in the process of submitting claims for reimbursement.
The guideline on “Appointment Records” discusses the matter of payment for missed appointments and certain arrangements to consider when a third party is involved.
The two Practice Bulletins that contain guidelines on “External Review of Psychoanalysis” and “Interacting with Third Parties” offer an approach and a method for seeking an alternative to a third party's usual claims review approach. An alternative is necessary because psychoanalysts and their patients often encounter claims review situations that fail to meet peer review standards. It is common to encounter reviews in which the appropriateness and “medical necessity” of the treatment plan are being determined by an outside party that is not a peer of the treating analyst and cannot be included in the ambit of confidentiality that surrounds good health care.
Peer review standards include the requirement that the reviewer for psychoanalytic treatment is a psychoanalyst who has been significantly immersed in the clinical practice of psychoanalysis for many years and who accepts the principles of confidentiality which govern psychoanalysis. Claims reviewers might be remotely familiar with psychoanalysis but rarely have actual clinical experience in the field. When applications for claims review arise with mental health treatment, it is important for psychoanalysts and patients to have the support of these two practice guidelines as they seek a mutually agreeable solution.
“Interacting with Third Parties” recommends that the patient does as much of the actual interacting with the third party as possible; so that the patient is thoroughly informed about the third party's practices and motivations. A well-informed patient is more likely to be able to arrange an outcome that will support a continued, viable psychoanalytic treatment plan.
From the beginning years of APsaA's guideline project to the present, APsaA's Committee on Peer Review has made a consistent effort to work with our colleagues from the American Psychiatric Association (APA) and contribute to its extensive practice guideline project. Sheila Hafter Gray, the former chair of this committee, has been at the forefront of this effort, leading our study and critique of almost every APA draft guideline. Wherever appropriate and practical, she has contributed well-documented suggestions (sometimes numbering as many as 100 for each guideline) that broadened the psychodynamic perspective in the text of psychiatric practice guidelines. Those of her recommendations that had a literature or evidence base, including our own Practice Bulletins, were readily accepted.
In a few important instances, Hafter Gray's suggested revisions have altered language in APA practice guidelines that otherwise might have resulted in very adverse conditions for psychoanalytic practice. For example, she worked closely with APA on a revision of the 1995 guideline, “Psychiatric Evaluation of Adults,” which is likely to be published this year. The 1995 APA document raised expectations that psychiatrists would be closely involved in a patient's general medical evaluation, including a physical examination. While APA has not rescinded these recommendations in its revision, significant progress has been made and it now seems likely that the new APA recommendations will be more flexible regarding the physical examination of patients by psychoanalysts and psychodynamically-oriented psychiatrists. This is a significant improvement, representing a successful liaison effort between APA, APsaA, and the American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP).
Because the advice given by the 1995 APA guideline has had widespread influence in creating community standards of practice that should not be applied to psychoanalytic practice, it is important that APsaA's practice guidelines be sufficiently clear. Therefore, the “Psychoanalytic Clinical Assessment” guideline states categorically that, “in contrast to recommendations for psychiatrists (APA, 1995), psychoanalysts and psycho-dynamic psychiatrists should not be expected or required to conduct physical examinations.” Knowledge of the interaction of bodily medical conditions upon psychic states, and of psychic states on bodily medical conditions, is often a vital part of psychoanalytic treatment. Patients regularly supply this information in the process of analytic exploration. If this method seems inadequate in a particular case, the guideline suggests that “the patient (or a minor's parent or guardian) can maintain privacy and confidentiality for the analytic treatment by acting as intermediary, obtaining and bringing copies of health-care records to the analyst.”
Psychiatrist-psychoanalysts who wish to practice in conformity with APA practice guidelines for psychiatrists will find it useful to view a psychoanalytic clinical assessment as a special form of mental health evaluation that is conducted in accordance with special parameters. This is, therefore, one of the noted exceptions to APA's requirement for documentation of the findings of a physical examination.
We have come to understand that the APA practice guideline project aims to reflect the position of American psychiatry today, and to indicate where it is headed. This includes the stance that the profession of psychiatry should emphasize its position as a medical science, in some instances even as a primary-care medical science, by conducting its procedures of patient care to resemble as closely as possible the procedures of other core medical specialties, such as the specialty of internal medicine. The process of creating the APA's practice guidelines has moved more and more away from the codified clinical experience of APA's membership, particularly the psycho-dynamic elements of that experience. The APA's Practice Research Network (PRN) and its extensive data set, which is available for use, is a good vehicle to learn what practicing psychiatrists are actually doing and what clinical approaches they find helpful. Instead of placing research into this PRN data set at the core of its practice guideline development process, the APA project chooses to focus heavily on data derived from controlled, randomized clinical trials. This form of research produces data and information that is readily accepted into current literature, perhaps to some degree because it is readily funded by medical industrial enterprises.
These choices and decisions advance the aim to position psychiatry, at least in the minds of government and third party payers, nearer to the center of medicine. This approach emphasizes the technical, physical, and experimentally provable aspects of the work, and de-emphasizes the patient-centered and “talk therapy” aspects of the work (for which substantial outcome studies are relatively lacking).
As more clinicians from the fields of psychology, social work, nursing, counseling, and other mental health clinical specialties become psychoanalysts, they will find that APsaA's guidelines clarify psychoanalytic practice on their behalf. Many of these licensed specialists have expressed concerns about issues of charting. Often, they were accustomed to the extensive charting procedures that are expected in many educational settings and mental health clinic practice. As these clinicians shift their procedures to fit their psychoanalytic work, APsaA's practice guidelines can provide support in case a licensing board or other outside party questions the charting practices that differ from the usual practices of their various specialties of licensure.
The committee encourages members to revisit all seven psychoanalytic practice guidelines (available now on the Public Information section of APsaA's Web site at ) and to study them as an integrated set. They provide new and stronger support for psychoanalytic practice, now and for the future.