Bulletin of the Psychoanalytic Research Society, Volume V, Number 1, Spring, 1996
A few months ago I received a letter from the insurance company of one of my patients. I was instructed to call a number and speak to one of their representatives. This was presented to me as a peer review.
My "peer reviewer" assured me that she was a psychologist from the community and so was a true peer. She seemed quite proud of this. She asked how my patient was doing and I answered in general terms. She then asked me to assign my patient to one of two categories, which boiled down to healthy or seriously disturbed. When I objected, she insisted that this was standard procedure. I nonetheless refused. She responded by asking me some additional questions. These questions focused on whether the patient could function adequately, and how much improvement she had shown during the six months I had treated her. I answered as honestly as I could without revealing specific details of the treatment.
After about ten minutes, the reviewer declared that she had enough information, and announced that she was ready to make her recommendation. She informed me that my patient no longer needed "intensive psychotherapy". As I was seeing the patient only once a week, I was confused. She explained that I could now see the patient once every two or three weeks. Again I objected. I wondered how the reviewer could come to such a conclusion based on ten minutes of talking with me, having spent no time at all with the patient. She told me that "research shows" that frequency of treatment sessions does not affect psychotherapy outcome, and that "other research shows" that psychotherapy is not effective past six months.
As it happens, I teach a doctoral level course on psychotherapy research and I am familiar with the psychotherapy outcome literature. I was not, however, familiar with any findings resembling those she described. Naturally, I was quite puzzled. I asked her what research she was referring to. This seemed to throw her off. Apparently, most people accept the reviewer's comments and then go on to argue in favor of their clinical judgment over the research findings. She said that "a lot of research" supported her assertions. I replied that with such a vast quantity of studies to choose from, surely she could cite one or two examples. She then told me that a recent issue of the journal Psychotherapy was devoted to process and outcome research. I asked her which article in that issue supported her assertions. She said that "most of them" did. I asked again for a specific citation. She could not answer.
My peer reviewer then took a slightly different tack. She switched from the journal and instead mentioned the name of a well-known psychology researcher who (she claimed) had conducted research that supported her views. As it happens, I know this person and had had dinner with him the previous week. I told her that I was acquainted with this man and his work, but knew of no evidence that supported her conclusions. At this point she became completely befuddled and told me that her recommendation stood regardless of my complaints, and that I had the right to appeal if I wished to do so. I assured her that I would and that I wanted that on record.
A few weeks later I received a letter from the insurance company informing me that ten additional sessions had been approved. The letter went on to say that "As always, treatment decisions are the responsibility of the patient and the provider, not [the insurance company]". They wanted me to sign this document and send them back a copy. I wrote back stating that since they had decided to terminate treatment after ten more sessions, against my advice, I would not accept responsibility for treatment decisions. I stated that any untoward reactions to termination would be solely their responsibility, and I wanted them to acknowledge this in writing. I soon received a reply allowing for continued visits until further notice.
A few months ago I was invited to attend a meeting of members of one of the more prestigious psychoanalytic institutes in New York. They were about to begin a clinical follow-up of some individuals that a few of the analysts had studied over twenty years ago, so as to write dynamic biographies of these individuals. I was called in to see if some empirical research could be added to the project. There were many prominent and even famous analysts present at the meeting. The first question asked of me was why I would be needed at all. I was asked to justify empirical research in the area of psychoanalysis. I did this to the best of my ability. In the course of a spirited discussion, one analyst blurted out that she did not see why "we" (the analysts) had to satisfy others when "our" methods were obviously good enough. She was quite indignant. Some agreed with her; some did not. Another prominent analyst announced that there was no need to be concerned about an interviewer being biased by previous knowledge about the interviewee as long as the analyst was "well analyzed". I was subjected to some more pointed questions concerning the usefulness of what I could offer, some mild support, and the meeting broke up. Some of the participants apologized to me. Others ignored me when the meeting ended. I never did become involved in the project.
I have gone into this narrative of my personal experience to make several points. First, the insurance companies are out to get us and if we remain passive, they will. They have no incentive to approve our claims, and a great deal of incentive not to.
Second, research (or more accurately the lack of research) is being used against us. This is because there is virtually no research showing that psychodynamic psychotherapy has anything of value to offer over and above other types of treatment. There are no data that suggest that long-term psychoanalysis is of any special value whatsoever. In fact, there is virtually no research at all addressing this issue. And we are doing nothing about it. If anything, psychoanalysts are aiding the insurance companies' cause through their semi-traditional hostility to researching psychoanalytic notions. There exists some sense among psychoanalysts that investigating psychoanalysis empirically will somehow sully it.
In a way, I was fortunate that my "peer" reviewer was so woefully ignorant about research. If she had been knowledgeable in this area, she could have told me that the type of work I do has no empirical support. Make no mistake: Insurance companies know this.
If you still can, remember these times as the good old days. They will soon be pleasant memories. And yet the psychoanalytic community does nothing. Worse, with only a few exceptions, the psychoanalytic community's views concerning research lie somewhere between bemused neglect and thinly-disguised contempt.
We are fiddling while Rome burns. Psychoanalytic institutes are not attracting the numbers (and some would say the quality) of candidates they once did. After all, what is the incentive for talented and intelligent clinicians to enter these institutes? Insurance practices discourage such entry, and the institutes can no longer provide their graduates with healthy practices.
Does anyone believe that someone else will serve the needs of psychoanalysis if we do not? Do you think that government officials will support psychoanalysis when insurance and pharmaceutical companies say they should not, and when we have no data to say they should? To become upset after the fact and rail against injustice at that point does not strike me as a useful coping strategy.
What shall we do? The powers that be will be perfectly happy to legislate us out of existence while we waste our time trying to determine: 1) what really constitutes psychoanalysis (Is it two or three times per week? Must the patient lie on the couch? How many angels can dance on the head of a pin?); and 2) whether empirical research really has a place in the corpus of psychoanalytic writings (After all, only information obtained in the analytic session has any bearing on psychoanalytic theory).
If the psychoanalytic establishment does not wake up and do something, psychoanalysis has no economic future. Established analysts at prestigious training institutes may limp along doing training analyses, but professionally speaking, the rest of us are as good as dead. We can, of course, do nothing but continue to enjoy inane conversations with "peer reviewer" shills for the insurance companies concerning what research does and does not "show". I leave it to the reader to decide whether this is a viable choice, and what the alternatives might be.