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Practice Bulletin 3 - External Review of Psychoanalysis

With the responsibilities, concerns, and needs of patients, psychoanalysts and third parties in mind, the Committee on Peer Review of the American Psychoanalytic Association has produced this guideline to provide a viable approach to the challenge of adequate external review of psychoanalysis and modified psychoanalytic treatment (CPT 90845),1 while simultaneously preserving the privacy and confidentiality of the patient and the integrity of the psychoanalytic process. This guideline serves to revise and replace all prior American Psychoanalytic Association standards, guidelines and policies on writing reports for external review of psychoanalysis (JTFDCA, 1976; CoPR, 1981; CoPR, 1985; Altschul, Gray, Rudominer, and Wylie, 1986; APsaA, 1992).

Since the American Psychoanalytic Association adopted its first guideline for reporting information for review of psychoanalysis and modified psychoanalytic treatment in 1976, there has been a major deterioration in the ability of third parties to maintain confidentiality of health care records. This committee’s study of this matter led it to conclude that in the current social and political climate one cannot expect that health care information will be kept confidential or private by third parties. Without significant remedy and improvement in these conditions, we believe that transmission of any patient information to any external party poses serious risks to the integrity of the psychoanalytic treatment alliance and to the prospects for successful psychoanalysis and modified psychoanalytic treatment. We recommend that a discussion of this situation form a significant part of the informed consent to review process that must be done with the patient if there is a request that any information be transmitted to any individual or entity that is external to the ambit of psychoanalytic confidentiality (Gray, Beigler, and Goldstein, 1997).

Reviews by third parties are fundamentally different from peer review. Peer review is a collegial process that is conducted within the ambit of confidentiality of a professional organization. Its ultimate aim is to assure that the professional services are appropriately selected and appropriately performed. Third party generated reviews (e.g. claims reviews, utilization reviews, and quality assurance reviews involving insurance companies, managed care companies, health maintenance organizations and government administrative agencies) are conducted by professional reviewers. Sometimes these reviewers are professional peers of the clinician, and sometimes they are not. In either case, such a review does not qualify as peer review because the professional reviewer is paid by the third party and must represent the interests of the third party.

Strict confidentiality is an absolute requirement for psychoanalytic treatment (Stone, 1961; Greenson, 1972; Langs, 1975; Etchegoyen, 1991). This requirement is supported in the Jaffee v. Redmond decision of the Supreme Court that maintained that effective treatment “depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories, and fears.” The Court upheld the principle that “the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment” (Supreme Court, 1996).

Review for the Initial Pre-authorization of Psychoanalysis

In the event that there is a request for external review by a third party, we recommend that the patient be referred to a consultant psychoanalyst who will conduct this review within the confines of strict confidentiality. No report regarding the content of the analysis is to be made as a result of this consultation process. With the patient’s informed consent, the consultant analyst is to report only a statement to the third party about whether or not psychoanalytic treatment is warranted.

On May 10, 1990, the Executive Council of the American Psychoanalytic Association first recommended that when psychoanalysis (CPT 90845) is prescribed in the context of third party authorization and reimbursement, and if the third party wishes to have the appropriateness of the prescribed treatment confirmed by someone other than the treating analyst, the patient “will see a consultant for a second opinion examination similar to that for elective surgery before this treatment is funded.” (Council, 1990) The consultant should be an appropriately qualified psychoanalyst peer of the treating analyst, acceptable to both the treating analyst and the third party. Preferably, such a consultant would be an experienced psychoanalyst who is certified by the Board on Professional Standards of the American Psychoanalytic Association or a comparable certifying body that the Board may designate and approve for these purposes.

Review for the Extension of Psychoanalysis

It has been demonstrated that after the initial pre-authorization review, frequent and detailed review of psychoanalysis is inappropriate because it tends to degrade the quality of the treatment (Gray, 1992). Third party requests for additional reviews tend to conflict with the requirements for successful psychoanalytic treatment (Cummings, 1995).

In the event that psychoanalysis proceeds significantly beyond the usual length2 and there is a request for external review by a third party, we recommend that the patient be referred to a consultant psychoanalyst who is selected as noted above. The consultant will conduct this review within the confines of strict confidentiality. No report regarding the content of the analysis is to be made as a result of this consultation process. With the patient’s informed consent, the consultant analyst is to report only a statement to the third party about whether or not psychoanalytic treatment is warranted to be extended and continued.

Progress Reports

There is consensus among clinical psychoanalysts of this Association that reports to third parties, outside the ambit of strict confidentiality, that focus away from psychoanalysis as a unitary procedure are substantially detrimental to the treatment process (Gray, 1992; Gray and Cummings, 1997); creation of such reports cannot be supported. Furthermore, when the claims review requirement for prior authorization of psychoanalysis or modified psychoanalytic treatment is appropriately established for a clinical case, there should be no need for additional reports.

1 - Modified psychoanalytic treatment (MPT) is closely akin to psychoanalysis, follows psychoanalytic practice guidelines, and is conducted in the context of the basic fundamentals of psychoanalysis, albeit with some modifications (e.g. in frequency of sessions).

2 - Criteria indicating the standard frequency of psychoanalysis and the point at which a psychoanalysis may be considered to extend beyond usual lengths are as follows: Standards of the American Psychoanalytic Association indicate that the minimum frequency of psychoanalysis is four sessions per week and that five or more sessions per week is often optimum. Modified psychoanalytic treatment (MPT) is often conducted at a frequency less than four sessions per week. Based on survey research by the Committee on Psychoanalytic Practice, the mean duration of a properly completed psychoanalytic case is approximately 1,000 sessions; therefore a psychoanalysis may be considered to extend beyond usual lengths at plus one standard deviation from the mean, or beyond 1575 sessions (Brauer, 1997).

References

Altschul, S., Gray, S. H., Rudominer, H, and Wylie, H. (1986). Reporting Information for Claims Review of Psychoanalysis. New York: The American Psychoanalytic Association.

APsaA (1992). American Psychoanalytic Association. Reporting Information for Claims Review of Psychoanalysis. In Mattson, M. (editor), Manual of Psychiatric Quality Assurance. Washington, D.C.: American Psychiatric Press, pp. 237–238.

Brauer, L. (1997). Personal communication of unpublished survey research on patterns of psychoanalytic practice.

CoPR (1981). Committee on Peer Review, American Psychoanalytic Association. Psychoanalytic Peer Review. In Committee on Peer Review, American Psychiatric Association (1981), Manual of Psychiatric Peer Review (Second Edition). Washington, D.C.: American Psychiatric Association, pp. 80–100.

CoPR (1985). Committee on Peer Review, American Psychoanalytic Association. Psychoanalytic Peer Review. In Committee on Peer Review, American Psychiatric Association (1985), Manual of Psychiatric Peer Review (Second Edition). Washington, D.C.: American Psychiatric Association, pp. 23–41.

Cummings, R. (1999). Psychoanalysis under managed care: the loss of analytic freedom. In Psychoanalytic Therapy as Health Care. H. Kaley, M. Eagle, D. Wolitzky, editors. Hillsdale, N.J.: The Analytic Press, pp. 103–117.

Etchegoyen, R. H. (1991). The Fundamentals of Psychoanalytic Technique. London: Karnac Books.

Gray, S. H. (1992). Quality assurance and utilization review of individual medical psychotherapies. Manual of Psychiatric Quality Assurance. Marlin R. Mattson, M.D., editor. Washington, D.C.: American Psychiatric Press. pp. 153–159.

Gray, S. H., Beigler, J., and Goldstein, J. (1997). Informed consent to review. J. Amer. Psychoanal. Assn., 45/2: 653–655.

Gray, S. H., and Cummings, R. R. (1997). Charting psychoanalysis. J. Amer. Psychoanal. Assn., 45/2: 656–672.

Greenson, R. (1972). The Technique and Practice of Psychoanalysis, Vol. 1. New York: International Universities Press.

JTFDCA (1976). Joint Task Force on Diagnostic Criteria for Analyzability, American Psychoanalytic Association. Psychoanalytic Peer Review. In Peer Review Committee of the American Psychiatric Association (1976) Manual of Psychiatric Peer Review (First Edition). Washington, D.C.: American Psychiatric Association, pp. 49–58.

Langs, R. (1975). The therapeutic relationship and deviations in technique. Internat. J. Psycho-anal. Psychother. 4:106–141.

Stone, L. (1961). The Psychoanalytic Situation. New York: International Universities Press.

The Supreme Court of the United States (1996): Jaffee v. Redmond (95-266), 518 U.S. 1 (June 13, 1996).

The American Psychoanalytic Association does not intend this practice guideline 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. This practice guideline was approved by the Executive Council of the American Psychoanalytic Association on December 16, 1999.

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