Book Review: PSYCHOANALYTIC THERAPY AS HEALTH CARE: EFFECTIVENESS AND ECONOMICS IN THE 21st CENTURY.  Edited by Harriette Kaley, Morris N. Eagle, and David L. Wolitzky.  Hillsdale, NJ: The Analytic Press, 1999

Review originally published in Journal of the American Psychoanalytic
 Association, 48 (2), 2000 and reprinted here with permission

Jane Buckwalter. PhD

           Psychoanalytic values, including confidentiality, neutrality, autonomy and self-determination of the patient, and especially the central importance of the treatment relationship, are dramatically opposed to managed care’s focus on the quick fix and the profit margin for the next quarter. The editors of this book offer a timely, multifaceted approach to the problems stemming from this polarity, in all forms of psychoanalytically informed treatment.

            The book is organized into four sections. The first presents an overview of the problems, with suggestions for the future, most chapters having been written for the 1994 American Psychological Association meetings with the theme Psychoanalysis as Health Care. A chapter by Bryan Welch describes the belated political awakening of psychologists and psychoanalysts, the gradual public awareness of managed care abuses, and the subsequent legal challenges that are beginning to hold managed care companies more accountable. Dorothy Cantor (mistakenly identified under “Contributors” as a former President of the American Psychoanalytic Association) gives a rousing call for psychologists to become politically active. One need only look at the figures in the Hay Group Study showing that mental health dollars paid by insurance have decreased 54 percent since 1988, while general health dollars declined 7.4 percent (National Association of Psychiatric Health Systems, 1998). James Barron, in his chapter, makes the important point that managed care has been able to use the positivistic, antisubjective viewpoint in psychology as an ally in the denial of subjectivity and the unconscious, focusing on target symptoms and excluding underlying characterological or causative issues. While the chapters in this section all present important aspects of the history of managed care, why we got where we are, and where we may be going, the use of “psychologist” should have been replaced by “analyst” or “therapist” when these chapters were rewritten for this book. While it may not in fact indicate the views of these writers, the use of  “psychologist” here appears to promote the division among our disciplines that has been a part of our delay in mobilizing a collective effort. 

            Companion chapters are written by Stanley Moldawsky and Marvin Hyman, who argue, respectively, that psychoanalysis is and isn’t health care. This is a core issue, given its implications for whether and how psychoanalysts are going to involve themselves politically to alter the system. Hyman, in presenting the viewpoint that psychoanalysis is not a health care profession, argues that in the medical model physicians assume responsibility for their patients, whereas analysts assume responsibility only for the analysis. While there is no doubt that the role of the patient in analytically informed treatment differs radically from the patient’s role in traditional medical care, Hyman would seem to minimize, perhaps in order to fulfill his assignment, the traditional patient’s role in prevention and wellness models. Moldawsky points out the various ways in which analysts are responsible for more than the analysis, as when patients are in need of medication or hospitalization, or, having suffered early trauma, need their analyst to validate the experience. 

            Another of Hyman’s arguments is that in the medical model the outcome expected is “conformity to a generally accepted state of normality or, at least, a cessation of complaints and symptoms” (p.61), whereas the outcome of an analysis is more subjective. While psychoanalytic goals are less concrete than medical ones, it does seem to me they can be conceptualized, as in the American Psychoanalytic Association’s Manual of Psychiatric Peer Review (1981), in a way that is not simply focused on signs and symptoms. J. F. Danckwardt and E. Gattig (1998), basing their views on Germany’s thirty years of experience with psychoanalysis first included in and then removed from national health care, think of third-party funding as a parameter: “Analytic treatments paid for by health insurance funds are medical treatments - that is to say, the analytic process must from the beginning be subordinated to the objective of eliminating or at least mitigating the symptoms of what is deemed to be an illness. Such limitations have modified the constitutive elements of psychoanalysis in the sense of introducing a parameter” ( p. 42). They believe that there are “great but unavoidable” dangers to including psychoanalysis in the system but that these can be met “if we are aware of them and pursue…research…so as to make a convincing case for the therapeutic potential of psychoanalysis” (p. 43 ).

            A closely related issue is whether psychoanalysis and managed care are compatible, and both Hyman and Moldawsky agree they are not. Robert Cummings’s chapter offers an excellent review of the reasons for this incompatibility. Moldawsky frames the issue as whether analysts can function first inside the system as psychotherapists, where they can show the value of psychoanalysis to patients for whom it is indicated, and then outside the system as analysts. I would add here the more difficult issue raised by Cummings, of whether “management” will be done in a way compatible with psychoanalysis, which certainly is not now the case (see Buckwalter 1999; Edwards 1999).

            Several writers suggest ways in which the profession is adapting to current economic realities (or could be), on the assumption that psychoanalytically oriented treatment will continue to be included in health care. Toni Bernay recommends that psychologists promote psychoanalytic short-term therapy as a “name brand product” to take advantage of managed care restraints and “position psychoanalysis as the powerful tool of a boarded (or niche) specialty of the premier mental health profession - psychology” (p. 19). This is an example of the unwitting arrogance of one discipline toward others, which only repeats what psychologists once experienced at the hands of the medical profession. Marylou Lionells, speaking from her experience at William Alanson White, discusses the need to “teach our students how to analytically study their participation in helping patients pay for treatment” (p. 69). She warns against the premature introduction, in response to economic pressures, of models for the condensation of intensive treatment, without careful thought for the model and its integration into the curriculum (p. 77).

            The second section of the book deals with issues of privacy and confidentiality. David Sundelson, a lawyer who coauthored The New Informants (1995) with Christopher Bollas, describes how our society has come to value the informer more than the healer (p. 100), with reporting laws protecting the informant more than the patient. Because mental health professionals have passively accepted the erosion of confidentiality with “inaction and … compliance,” HMOs and insurance companies have been able to demand extensive disclosure of confidential information. I would agree with Sundelson that we need to reestablish for the psychotherapist-patient relationship the professional discretion regarding disclosure of confidential information that holds for the lawyer-client and priest-penitent relationships. This need to protect confidentiality must be advanced to alter managed care procedures. Cummings points out that “properly conducted peer review adequately protects patients’ confidentiality” (p. 110), when it is done by independent reviewers, free from conflict of interest and appropriately credentialed and experienced, as opposed to agents of the HMO or insurance company.

            I like Russ Newman’s expression: cost-containment neurosis. He describes the loss of confidentiality, for cost-containment reasons and out of concern over child abuse, as overreactions, “self-defeating attempts] to solve an immediate problem and alleviate current anxiety while actually perpetuating the very problem the neurotic behavior is intended to address” (p. 120). Referring to two California cases, Newman notes that “courts have held that a third-party payer or managed care entity can be held responsible for negligently designed or implemented cost-containment strategies that result in patient injury” (p. 122). This suggests an important legal approach to current managed care cost-containment strategies involving extensive gathering of confidential information.

            The third section, “International Perspectives,” with a chapter written jointly by Brent Willock, Christa Balzert, Ahmed Fayek, and Julian Abraham and another by Ron Spielman, gives valuable descriptions of the fate of psychoanalysis and intensive treatment under various national health plans. These chapters examine the way the different mental health disciplines are treated, the degree of interference with clinical decisions and what happens when psychoanalysis opts out of a national health insurance plan.  When the British Psychoanalytic Society took this step, the result was that psychoanalysis became primarily limited to London. Where there is universal health care, governments do just what the insurance industry is doing here - making decisions that in effect constitute rationing.  (As Cummings points out, managed care companies couch rationing in the seemingly more benign language of “medical necessity.”) Those who would involve themselves in the political struggles around funding for psychoanalysis and intensive treatment in this country would do well to learn from the experience of others around the world.

            The final section of the book, “Current Issues and Special Populations,” aims to counter the idea that psychoanalysis is for the “worried well” and for the wealthy. Norman Doidge writes of a Canadian survey of psychoanalytic patients, which he says is consistent with other surveys, showing high rates of childhood trauma, multiple current psychiatric diagnoses, indicators of chronicity, and frequent previous attempts at less intensive therapy. All this counters the idea that individuals in psychoanalysis are “paragons of mental health,” as they were described by Manitoba’s Chief Medical Assessor just before psychoanalysis there was deinsured. In that same survey, the mean income of patients was that of a starting teacher’s salary.

            Mark Blechner writes about the HIV Clinical Service at William Alanson White, and Neil Altman describes work with an inner-city population. Sidney Blatt and Richard Ford in one chapter and Eric Plakun in another describe the Austen Riggs Center’s psychoanalytically informed intensive inpatient treatment of seriously disturbed, treatment-resistant adults for whom other forms of treatment have been ineffective. These chapters document the wide range of applicability of psychoanalytically informed treatment.

            I believe it possible to include psychoanalysis and intensive psychoanalytically oriented treatment in health care reimbursement systems, while using procedures of accountability that preserve confidentiality and are fairly compatible with the analytic process. We must anticipate, however, that psychoanalytic theory and technique will  remain subject to political and economic pressure. This book is an excellent resource book for professionals who would better inform themselves of the various ways the funding policies of government and private insurers affect psychoanalytically informed treatment. More important, we need books like this to inform and inspire us to educate the public and our legislators. To implement our values, we need to participate in lobbying and litigation. If analysts don’t do this, who will?  As Cummings poses the question, perhaps not altogether overdramatically, “Will American psychoanalysts retain analytic freedom and continue to make this country a safe harbor and a fountainhead for psychoanalytic thought, education, influence, and practice; or will American psychoanalysts become the next refugees from a land where analytic freedom has been lost?”  (p. 115).

 References

American Psychiatric Association (1981). Manual of Psychiatric Peer Review. 2nd ed. Washington, DC: American Psychiatric Association.     

Bollas, C. & Sundelson, D. (1995). The new informants. Northvale, NJ: Aronson.

 Buckwalter, J. (1999).  On becoming managed: Managed care enters a psychoanalytic treatment. Journal of Clinical Psychoanalysis  8:125-137

Danckwardt J.F., & Gattig, E.  (1998). Psychoanalysis in the German health insurance system. International Psychoanalysis: The Newsletter of the IPA 7:41-43.

Edwards, J. (1999). Is managed mental health treatment psychotherapy? Clinical Social Work Journal  27:87-102.

National Association Of Psychiatric Health Systems (1998). News Release on The Hay Group Study, May.