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, and subject 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.
Reference
Gray, S. H. (1992). Quality assurance and utilization review of individual medical psychotherapies. Manual of Psychiatric Quality Assurance Review, ed. Marlin R. Mattson. Washington, D.C.: American Psychiatric Press, pp. 159-166.
This Practice Bulletin was prepared by the ad hoc Task Force on Informed Consent to Review of the American Psychoanalytic Association, Sheila Hafter Gray, M.D. (chair), Jerome S. Beigler, M.D., and Joseph Goldstein, LL.B., Ph.D. The text was approved by the Executive Council of the American Psychoanalytic Association on December 19, 1991.
The American Psychoanalytic Association does not intend this Practice Bulletin to state or serve as a standard of practice for mental health care. It is intended as a guideline only. The ultimate judgment regarding a particular clinical decision or method of intervention or overall treatment plan will be made by the practitioner on the basis of the clinical data presented by the patient and the diagnostic and treatment options available in the particular clinical setting.
Model Release Form
This Model Release follows the format suggested by the District of Columbia Mental Health Information Act. It should be reviewed and modified by legal counsel to assure that it conforms to local and state law in the jurisdiction in which it will be used.
Patient Authorization for Release of Medical Information
I, [Patient], hereby authorize [Psychoanalyst] to release to [Review Organization] of [City and State] the Psychoanalytic Individual Treatment Plan concerning my case. I understand that [Review Organization] will review my Individual Treatment Plan to determine whether my treatment is covered in whole or in part by the health insurance plan in which I am enrolled.
These Psychoanalytic Individual Treatment Plan reports may include the following information about me and my treatment:
(1) administrative information (e.g., name, age, sex, address, dates and character of sessions);
(2) diagnostic information;
(3) status as a voluntary or involuntary patient;
(4) summary of my current clinical condition;
(5) history relevant to my current clinical condition;
(6) treatment plan including reasons for past and current treatment and short-, intermediate-, and long-term treatment goals and the criteria that will be used to judge whether they have been attained;
(7) prognosis consisting of estimate of time to achieve treatment goals.
The authorization extends solely to written disclosure of information. The authorization applies solely to the release of the Psychoanalytic Individual Treatment Plan(s) written on or before the date of this release.
Before I signed this release I studied the Psychoanalytic Individual Treatment Plan documents and I discussed their contents with [Psychoanalyst]. I also discussed with him/her the possible risks to my treatment of transmitting this information, and the possible benefits I might gain from external review of my treatment. I countersigned each Plan to show that I approved its contents and agree that it may be forwarded to [Review Organization].
[Insert any special language mandated by state law.]
I understand that this consent is revocable, and that it does not apply to documents that I have not had an opportunity to study.
Patient__________________________________ Date____________
Further information relating to disclosure of information can be found in [cite specific state or federal legislation or regulations that may apply].
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Last revised 10/13/95