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JOURNAL OF PSYCHOThERAPY PRACTICE AND RESEARCH
Developing Practice Guidelines forPsychoanalysis
SHEILA HAFTER GRAY, M.D
Consensus-based pra dice guidelines cod�ft
dinical intelligence and the rich oral tradi-tion in medicine. Because they reflect actual
practice, they are readily accepted by dini-
cians as a basis for external review. This arti-
cle illustrates the development of guidelinesfor a psychoanalytic approach to the large
pool ofpatients who present with a depres-
sion. It suggests an integrated biopsychosocial
approach to these individuals that is useful in
current practice, and it offers propositions
that may be tested in future research under-takings. Eventually, practice guidelines such
as these may form the basis of economical sys-
tems of health care that avoid arbitrary, dini-cally untenable limitations on services.
(The Journal of Psychotherapy Practice
and Research 1996; 5:213-227)
In this article, I will outline how psychiatrists
may formulate practice parameters in away
that benefits our professional development
and the care we offer our patients. Practiceparameters are strategies for patient manage-
ment that are developed to assist physicians in
clinical decision making. They describe the
range of acceptable approaches to diagnosing,
managing, or preventing specific diseases orconditions. Because they reflect the diversityof clinical medicine, practice parameters vary
considerably in content, format, and degree ofspecificity. Some are standards; some are
guidelines. They may be based on statisticaloutcome studies or on clinical consensus.
Outcome-based parameters derive theirstrength but also their weakness from theirresearch foundation. Although there have
been several good outcome studies on psycho-analysis,’ the body of knowledge is inadequateto form the basis of a generally applicablepractice parameter. At present, guidelines forpsychoanalysis derived from outcome studies
alone would be incomplete and difficult to
implement.
Consensus-based practice guidelines fo-cus on the experience of clinicians, and they
acknowledge the complexity of the individualpatient. They codify and integrate existing
clinical intelligence and the rich oral tradition
Received June 8, 1993; revised February 22, 1996; ac-
cepted February 28, 1996. From the Department of Psy-chiatry, University of Maryland School of Medicine,Baltimore, Maryland, and Department of Psychiatry,
Walter Reed Army Medical Center, Washington, DC.Address correspondence to Dr. Gray, P.O. Box 40612,Palisades Station, Washington, DC 20016-0612.
Copyright © 1996 American Psychiatric Press, Inc.
214 GUIDELINES FOR PsYcHo�i�YsIs
VOLUMES #{149}NUMBER 3 #{149}SUMMER 1996
in medicine. This makes them better suited
than outcome-based parameters for the task ofhelping the psychiatrist integrate the biopsy-chosocial aspects of a case. Their delineationof actual contemporary practice also serves
the research goal of defining patterns of prac-
tice that are appropriate for scientific investi-
gation.
TOWARD
GUIDELINES
DEVELOPING
Allocating Therapeutic Resources
One ordinarily bases the allocation of
therapeutic resources on medical necessity.
Peer review is the traditional procedure to
monitor this process.2 When we delineate theknowledge base we implicitly use in this peerreview process, we have taken a first step in
the development of a practice guideline basedon clinical consensus.
The nature of psychotherapy and psycho-
analysis requires that this effort to codify be
principled, voluntary, and based on broadconsensus among practitioners. The guide-
lines must respect and protect the special
doctor-patient relationship that makes psycho-
therapy possible. They must contain a large
measure of appreciation of the individual dif-ferences among patients and among psychia-
trists. In the absence of definitive knowledgethat mandates an unequivocal treatment plan,they must accommodate a range of theoreticaland practical approaches to a disorder, and
they must state criteria for a successful out-
come. They must do all these things not in an
ideal space populated with paragon patients,
but in a context of clinical reality.
I selected medical psychoanalysis (CFT
90845) as the model psychotherapy to study
from this perspective. My earlier work3 re-vealed that principles and procedures that sup-port this modality are generally useful forother individual medical psychotherapies(CPT 90844). I selected the specffic clinical
situation ofa patient who presents with depres-
sion because the American Psychiatric Asso-
ciation was working on the Practice Guidelines
far Major Depressive Disorder in Adults.4
Issues Relevant to Constructing Guidelines
ImportantSubjeaMauerk Unknown: Classicalpsychoanalysis and certain schools of dynamic
psychiatry rest on a fundamental assumption
that people are motivated by ideas and feel-ings of which they are unaware and of whichthey cannot spontaneously become aware.5These motive forces are responsible for the
formation of symptoms, dreams, and person-ality.6 Behavior-oriented psychoanalytic theo-
rists assert similarly that mental disorders
contain an important component of dis-
avowed or unacknowledged wishes.7 We
avoid the problem of unknown mental con-tents by focusing on observable aspects of the
patients. These are presented in terms of theformal mental status examination, a full DSM-
N diagnosis, and a description of the patients’
actions, including their verbal activity in the
sessions. This approach lacks metapsychologi-
cal mystery, but it is accurate and replicable.Kantor� has delineated the diverse findings ofthe mental status examination in Axis I andAxis II disorders in a way that integrates thebiopsychosocial aspects of each case.
Outcomes Are Unique: Psychoanalytically in-
formed dynamic psychotherapy focuses onthe patient’s inner life. Its aim is described bysome as the development of insight or self-un-
derstanding,’#{176} the revision of one’s history,”2or the construction of a coherent and comfort-able sense of self.’3 It may involve the discov-ery of memories of which patient andpsychiatrist are, by definition, initially igno-
rant5 Awareness is the anticipated conse-quence of a process that begins with theestablishment of a special doctor-patient rela-tionship, the therapeutic alliance,’4 and goeson through the elucidation of here-and-nowtransferences to the point at which one re-members or reexperiences the associated pastdifficulties and reevaluates them in light ofcontemporary circumstances. One may then
215
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
develop a more coherent sense of self, or
restructure one’s personality, or rewrite one’shistory, or resume emotional growth.’5 Be-
cause the description of these outcomes isunique to each case, to operationalize thesevariables for an outcome study may at this
time be beyond our technical grasp.’6
The Review Process Always Changes The Case:
Each method of review, including a clinician’sself-review, has its particular risks and benefits.Each must be scrutinized from the viewpointof its impact on the clinical psychotherapeuticsituation and its specific meaning or meaningsto the patient. Lipton,’7 for example, docu-
ments the adverse impact on cases of ordinary
scientific communication. Because of this phe-nomenon, psychoanalytic cases are extraordi-narily difficult to review.
Writing Notes Degrades Technical Qjtality: A sub-committee of the Committee on Peer Review ofthe American Psychoanalytic Association re-cently studied this problem. It concurred withAdams-Silvan’8 that the process of creating
daily notes itself violates the core psychoana-
lytic technique of listening with even-hovering
attention.’9 Notes are therefore not likely to be
available as a database for review of psycho-
analysis.
Extending Clinical Consensus
Following dynamic treatments over the
long term, then, is complicated by the unique-
ness of each procedure, by the requirement topreserve the therapeutic alliance, and by the
possibility that the review process will sabo-
tage the therapeutic process. In this environ-
ment, practice guidelines might be viewed as
another ruinous encroachment on the delicate
doctor-patient relationship.
I propose that we may mitigate this out-
come if we construct guidelines by a process
of clinical consensus that reflects the special
technical problems of psychoanalysis. In 1975,
agroup of psychoanalysts of the Baltimore and
Washington Psychoanalytic Societies who
were members of the Washington Psychiatric
Society did just that The joint Committee ofthe Washington and Baltimore-District of
Columbia Psychoanalytic Societies for Estab-lishing Peer Review Standards for Psycho-analysis developed guidelines for peer reviewof psychoanalysis and modified psychoana-lytic treatment of adults, adolescents, and chil-dren. These guidelines served the DistrictBranch well in its cooperative work with theUtilization and Peer Review Committee of theMedical Society of the District of Columbiaand with the American Psychiatric Associa-
tion’s Peer Review Projects. Colleagues
tended to heed comments based on these
guidelines because they owned them. This
report describes an effort to continue this ap-
proach at the national level.
METHODS
This project stems from an effort to gather factsand opinions on which to base the AmericanPsychoanalytic Association’s response to the
American Psychiatric Association’s Draft
Practice Guidelines for Major Depressive Dis-order in Adults. I solicited comments frommedical psychoanalysts from components of
the American Psychoanalytic Association,asking them to focus on how they approachedpatients who presented with depression.
About thirty individuals who had been se-lected to speak for their local groups offeredwritten contributions. I encouraged the col-
leagues to tell me what they do and, if theycould, why they do it. We also held three smallhalf-day conferences at the scientific meetingsof the Association. I used a traditional psycho-analytic methodology, listening to people, un-derstanding the basis of their concerns and theiractivities, and reflecting this understanding backto them in their own language20-the techniqueof clarification.2’ I tried to abstractfrom ourlaz�ge
psychoanalytic case literature principles thatseem to have guided dinicians toward certain
interventions and away from others. I set out theprocess in a logic-driven procedure diagram,�which I asked colleagues on the Committee on
216 GUIDELINES FOR PSYCHOj�T��YSIS
VOLUME S #{149}NUMBER 3 #{149}SUMMER 1996
Peer Review to test The aim was to have a set
of explicit statements that reflected actual
clinical practice.
RESULTS
The American Psychoanalytic Association’s
early guidelines for prescribing psychoanaly-
sis� are expressed diagrammatically in Figure1. The procedure diagram I developed (Figure
2) incorporates these early guidelines. It de-
lineates my best assessment of how good-
enough psychoanalysts, to use Winnicott’sconcept, approach a person who complains of
depression. Both diagrams await field trials,based on which there may be further revisions
before official action by the Association.
Psychoanalytic Treatment of
Patients Who Present With Depression
We begin with an undifferentiated groupof patients, and in successive steps we isolate
those who require and can benefit from psy-choanalysis. In this system, psychoanalysis is
the treatment of last resort
In itial Assessment: We begin with a rapid as-sessment designed to answer the question,
“Does this individual suffer from a mentaldisorder?” This guideline is based on the
DSM-N notion of a continuum of depressivedisorders from Uncomplicated Bereavementthrough Adjustment Disorder With DepressedMood to Major Depression, MelancholicType. This continuum is a notion based onFreud’s germinal work Mourning and Melancho-
lia.24 It is thus congenial to psychoanalysts. Italso recognizes that personality disorders may
impair the patient’s capacity to deal with de-pression. From this perspective, psychoanaly-sis represents inappropriate treatment forbereavement and other V-code problems,even when the patient meets criteria for ana-lyzability (see Figure 1). If, however, mourn-ing does not resolve within culturallynormative guidelines, the clinician fullyreevaluates the individual to decide whether a
psychiatric disorder interferes with this ordi-nary adaptive process or has been precipitatedby the loss.24� In practice, one leaves the dooropen to these V-coded patients to return if
mourning is inhibited or prolonged.
Mental health professionals may presentfor treatment as part of their education or to
enhance their therapeutic skills. They rarelycan endorse a true chief complaint, althoughthe prevalence of subclinical dysthymia in this
population2�28 steers many of these individu-als to endorse depression as their problem.Rather than isolate these cases, one asks thatthey endorse a chief curiosity in lieu of a chief
complaint and loops them back into the mainstream of psychoanalysis and psychotherapy.This maneuver allows us to monitor the qual-
ity of psychotherapies undertaken for training
purposes and makes the peer review proce-dure available to education committees fortheir special quality assurance work.
This guideline stresses the importance ofa full biopsychosocial evaluation. Correct phe-nomenological diagnosis is essential, but omit-ting early and conscientious assessment of thedynamic components of a case29 frequentlyleads to clinicians’ overlooking important as-pects of a patient All psychiatry, and particu-larly psychoanalytic psychiatry, seemshaunted by the DSM-II position that majordepression and so-called neurotic depressionare mutually exclusive.30 This colors theAmerican Psychiatric Association’s PracticeGuideline4 position on psychotherapy for ma-jor depression; it also influences the way olderpsychoanalytic colleagues think about de-
pressed people. It leads some clinicians to
overlook the power of mulhimodal treatment
for patients who function at a neurotic level,and it leads others to underutilize psychother-apy for patients with high-level personality
disorders when they present with a severedepressive disorder that clearly requires andresponds brilliantly to a biological treatment
Trial of Individual Medical Psychotherapy: Acourse of brief individual medical psychother-apy accomplishes several functions concur-
GRW 217
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
rently. It quiddy provides the patient with a
segment of psychotherapy. It allows the clini-
cian an opportunity to complete a detailedassessment of the case and to complete theinitial treatment planning process. For cases inwhich long-term psychotherapy or psycho-
analysis become options, it serves as a test ofthe patient’s capacity to work effectively with
the therapist in an insight-seeking mode.We reassess the patient quicidy after three
sessions of psychotherapy to verify that thecase is stabilizing. We abort the treatment andreevaluate the case if the patient’s condition isdeteriorating. This is also the point at whichwe first consider medication. The guideline
states clearly that psychophannacotherapy isan integral element of medical psychoanalysis,
and the procedure diagram shows points atwhich we might consider and administer this.
We know that many patients with major de-pression have a true neurosis3’ and respondwell to a combined approach.32 Several senior
colleagues nationwide informed me that thecombined approach has been state-of-the-artin their local group for some time. In an
unrelated survey, Doidge found that of 641psychoanalytic patients treated by 237 active
members of the American Psychoanalytic As-sociation, 92 (14.4%) were on an antidepres-
sant medication, and slightly more than half ofall patients who are treated concurrently withpsychoanalysis and pharmacotherapy were
medicated by their treating psychoanalysts(Norman Doidge, M.D., personal communi-
cation).At the completion of this module, some
patients may require no further treatment or
continuing psychotherapeutic management ofthe biological treatment Other patients maydisplay either disturbances sufficient to man-
date full reevaluation or indications for anintensive insight-seeking treatment This is a
good point for a pre-authorization review. Atthis lime one needs ordinarily to consider a
range of treatment options, but I noted thatpsychoanalysts tended to gravitate toward rec-
ommending psychoanalysis or a closely re-lated psychotherapy rather early in this
process. This represents a potential weak pointthat can be addressed by external pre-authori-
zation review. If psychoanalysis is determinedto be the preferred treatment, we go to a
further brief technical assessment and a clini-cal trial. This may be followed by a moredefinitive pre-authorization review based on
observations of the patient’s actual perfor-mance in psychoanalysis. The advantage ofthis approach is that we have early informationabout the patient’s need for and capacity to
work within this demanding modality, and wehave optimized the chances for success by
having corrected any underlying biological
imbalance through medication.
Trial of Psyc/zoana�5isis: This guideline followsthe 1975 consensus of the Baltimore and Wash-ington psychoanalytic colleagues that the
treating psychoanalyst should reevaluate a
case after 1 year to ensure the appropriatenessof the initial prescription. Formal reassessmentprovides an opportunity to rediagnose, to note
progress, and to identify and correct errors inthe treatment plan. It also allows patients an
opportunity to accept indicated medicationthat they may have declined earlier. After a
successful trial of psychoanalysis we continue
treatment and reassess periodically.
Progress: Patients demonstrate progress in
psychoanalysis in the way they work with the
analyst to achieve self-understanding and re-sume emotional growth.3 The guideline doesnot take a position with respect to the nature
of these events, leaving each clinician free to
define criteria that reflect his or her theoreticalviews. These subjective criteria are reflected
objectively in three places in the DSM-Ndiagnosis. The Axis V GAF score will risedramatically as patients confine their symp-toms to the psychoanalytic situation and thetransference neurosis consolidates, then risegradually as treatment goals are realized. Con-sequently, an external reviewer must guardagainst disallowing treatment based on an im-proved Axis V. Our knowledge of how psy-choanalysis works suggests that the failure of
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JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
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GRAY 223
224 GUIDEUNES FOR PSYCHOANALYSIS
VOLUME 5. NUMBER 3� SUMMER 1996
Axis V to soar should trigger reassessment In
later phases, progress is confirmed objectively
by the disappearance of the Axis I disorderand by changes along Axis II that reflectgrowth in the structure of the patient’s person-ality; Axis II Cluster B disorders will be super-seded by Cluster C disorders. At termination,
ideally all psychosocial diagnoses disappear
and their biological components are in remis-
sion.
Complications: This guideline keeps us alertto the possibility that the patient’s condition
may worsen during treatment In cases of se-rious depression, worsening can cause a lethaloutcome.
We may view psychoanalysis and dy-namic psychotherapy as modalities that offerunderstanding. Their essential neutrality al-
lows patients to use insight to improve theirmental health or to perfect their mental disor-
det The negative therapeutic reaction is a
special class of complication in which theworsened condition may reflect technical
progress in the treatment This guidelinepresents an initial attempt to define a way inwhich the psychiatrist may evaluate suchcases and create an appropriate treatmentplan for each.
CASE ILLUSTRATIONS
The following two cases illustrate aspects ofdecision making in the treatment of depres-sion without (Case 1) and with (Case 2) the useof the practice guidelines.
Case 1. Wylie and Wylie32 reported the case ofa 39-year-old administrator who consulted a psy-choanalyst because she could not establish a satis-factory long-term relationship with a man. Shewas also anhedonic. She had struggled for manyyears with intermittent episodes of depressionthat were refractory to tricycic antidepressantsbut responded well to amphetamines. After an in-
itial assessment� the psychiatrist found that the pa-tient met thepublished diagnostic criteria foranalyzabtht� and instituted psychoanalytic treat-ment.
Eighteen months into a dassical psycho-analysis it was clear that the patient was unable to
grasp the special quality of transference related-
ness, she was depressed, and she continued to bereluctant to risk an emotional investment in thetherapeutic relationship. The history that had
been gathered in the course of analysis revealed asevere sensitivity to rejection and a prodivity forseWinjurious behavior. At this point the psychia-that prescribed a monoamine oxidase inhibitorand continued the psychoanalytic treatment
One month later, the patient spontaneouslyacknowledged transference feelings within theanalytic session. Soon thereafter she was able tocollaborate with the psychoanalyst to develop in-
sight; and 2 years later she had achieved her treat-ment goal& The patient continued to do well at a10-year follow-up visit (Harold W. Wylie,Jr.,M.D., personal communication).
This is one of the earliest published ac-counts of antidepressant medication used in
conjunction with classical psychoanalysis. Ap-plying the proposed guideline (Figure 2) retro-
spectively to this case, we note immediatelythat psychoanalysis was instituted without atrial of psychotherapy adequate to ascertainwhether the patient was able to work in an
insight-seeking mode. Having failed to estab-lish this point, the psychiatrist continued thepsychoanalysis without evidence of progress
and without consideration of pharma-cotherapy for 18 months. The psychiatrist dideventually come to understand the nature ofthe problem, reassessed the case, and imple-mented a treatment plan that resulted in a
good outcome in a short time.
Had these guidelines been available at the
time this case was treated, the psychiatrist
might have recognized early both the need to
ascertain that the patient could work in aninsight-seeking mode and the importance ofconsidering medication if the initial trial ofpsychotherapy proved inauspicious. Even ifhe and the patient had chosen to do onlypsychoanalysis, it is likely that his early find-ings would have set the stage for continuousassessment of progress and of the possible use
of medication. This process might have short-
ened the treatment by as much as a full year.
GRAY 225
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
Case 2. A 40-year-old scholar came to me for asecond opinion consultation at the request of the
treating psychiatrist, who questioned the appro-priateness of continuing psychoanalysis withoutantidepressant medication.
The patient had first consulted the psychia-trist 15 months earlier complaining of unpleasantfeelings compounded of anxiety and guilt thathad become increasingly intense over a period of2 years. He viewed them as a response to con-ificts related to a parent’s suffering and eventualrecent death after a long illness. Although he hadharbored similar guilt feelings subdinically foryears, they seemed to be experienced as back-ground noise that did not interfere with optimal
functioning. There had been a course of individ-
ual psychotherapy 20 years earlier in connectionwith discomfort over academic performance. Heexperienced it as helpful but incomplete.
When the patient first presented to the psy-
chiatrist,depression was the salient clinical find-
ing. He wept often and manifested disturbed
sleep patterns, anxiety, irritability, and poor self-esteem. The psychiatrist recommended Individ-ual Medical Psychotherapy (CPT 90844) at a
frequency of twice weekly; the prescription ex-plicitly included antidepressant medication. Thepatient declined the latter.
Three months later, when he had gained
some insight but did not achieve full symptom re-lief and did not seem to be well engaged in the
mourning process, the psychiatrist again called at-tention to the appropriateness of pharma-
cotherapy. This practice conforms to the
guideline for reevaluation of the treatment plan at
the completion of brief psychotherapy (Figure 2).The patient again rejected medication and aflirm-atively requested psychoanalysis. After careful as-sessment, the psychiatrist agreed. At this point,the plan met guideline criteria because it was de-veloped after appropriate reassessment. They be-gan work in this mode about 1 year before theconsultation. They were now at the time of the
major reassessment mandated by local guidelines
and recommended by this guideline.
The patient arrived precisely on time andsettled down to the interview after I made a briefexplanation of the function and scope of my in-
quiry. Pale, flawlessly groomed, and dressed in awell-cut charcoal gray suit, black shirt, tie, and
pocket handkerchief, black hose, and blackshoes, the patient appeared a picture of continu-ous, sophisticated mourning. His demeanor was
subdued and somewhat apprehensive. He sat di-redly opposite me in the consulting room and ad-
dressed my questions and comments slowly,carefully, and in some detail; yet he revealed
very little. He spoke in two voices. One was low-pitched, authoritative, and masterful. The otherwas higher in pitch; it bore faint traces of a Brit-ish academic accent, but the overall impressionwas of childish vulnerability. The latter voicedominated.
The patient fussed about the formal mental
status examination, insisting that the items weretoo difficult When I remarked quietly that a de-
mented individual was certainly not analyzable,he quickly tackled the problems, doing well onthose that required abstract thought He endorsedsuicidal thoughts in the past; these did not reach
the level of a plan. He also endorsed Irritability,forgetfulness, and fantasies of vengeance. He de-nied anhedonia and substance misuse The pa-tient denied ever having seen visions or heardvoices of absent persons; he also denied ideas ofuniqueness or of persecution. He had not faintedor had epileptic attacks, including “absences.” So-
cial judgment seemed good. Performance on two
formal tests of long-term memory seemed Im-
paired by poor concentration; short-term mem-ory seemed adequate.
DSM-IVDiagnorLc: Axis I: 296.21 MajorDepression, Single Episode, Mild; Axis 11:799.90Diagnosis Deferred; Axis ifi: No physical condi-tion that affects the mental status; Axis N: Deathof parent; Axis V: 55 Moderate symptoms of de-pression and anxiety and some difficulty in socialfunctioning.
The patient may have presented with a majordepression, single episode, severe without psychoticfeatures (DSM-N 296.23). The severity of the disor-der abated, but he still endorsed symptoms of amild major depression. It was not possible to diag-
nose a specific personality disorder in this single in-terview. It seemed likely that the anxiety hereported signaled the emergence of an Axis 11 disor-
der out of a previously stable and adaptive personal-ity style that faltered in response to the stress of the
parent’s illness and death.
Although psychoanalysis is very often thetreatment of choice in cases where the majortherapeutic effort must focus on the personality
(Figures 1 and 2), it was clear that after a year oftreatment the patient remained mournful. Accord-ing to the proposed guideline (Figure 2), a trial ofmedication had been indicated earlier and had
226 GUIDELINES FOR PsYcHoAr�LYsIs
VOLUME 5 #{149}NUMBER 3 #{149}SUMMER 1996
become even more important because he hadmade inadequate progress without it In the con-
sultation, I explained to the patient that the pres-
ence of an Axis I disorder, even in subclinicalform, can and does interfere with the psychoana-lytic treatment of an Axis 11 disorder. Medical
psychoanalysis (CPT 90845) that includes psycho-pharmacology for the Axis I disorder has an ex-cellent chance of success in addressing thebiological and psychosocial aspects of the disor-
der in a coherent and definitive fashion. I sup-ported the treating psychiatrist’s prescription ofthis multimodal approach, recommending thecontinuation of medical psychoanalysis only if itinduded the medication component.
Discuss ION
The effort to establish expert guidelines for anew or revised health care system can lead to
conflict with clinicians because expert guide-
lines favor outcome research over clinical
inteffigence.33 Although outcome-based pa-
rameters have the advantage of their researchfoundation, they also have its disadvantages.
One is a reliance on statistical studies withproblematic methodology.34’35 Another is that
the present funding environment may have
influenced researchers to neglect inquiry intothe effect of definitive care over the lifetime ofan individual. A third is that because few
specific interventions have been studied, prac-
tice parameters based on outcome studies are
incomplete, and psychiatrists therefore en-
counter obstacles when they try to implementthem in daily practice.
Consensus-based practice guidelines aim
to codify the oral tradition in medicine. Theyare particularly useful in psychoanalysis be-
cause psychoanalytic education is grounded in
detailed discussion of single cases with a senior
teacher. Because they reflect actual practice,
they are readily accepted by clinicians.36
The development of such guidelines con-tains a risk of endorsing suboptimal treatment
choices. Two pathways are available to miti-gate this danger. First, one may use these
guidelines as propositions that will be tested in
future research. Second, if the consensus pro-
cess reveals an area in which a professional
group did not revise its clinical behavior inresponse to the emergence of new scientificinformation, its leaders may use the findingsof consensus studies such as this one to de-velop an educational strategy that targets theparticular defect
As a by-product, these guidelines define a
common ground for clinicians and lawyers.
Practice guidelines can support the colleaguewho is sued by providing dear statements aboutacceptable technique. l)etailed discussion of thissubject would require another paper.
These guidelines based on emerging clini-
cal consensus help us detect which individuals
in the large pool of patients who present with
a popular complaint that covers a wide spec-
trum of psychopathology require and may
benefit from psychoanalytic treatment The
guidelines remind us that many patients who
have a biological predisposition to depressionalso have serious neurotic conflict and that wemust look beyond medication and support to
substantive dynamic treatment for these indi-
viduals. Simultaneously, the guidelines helpwinnow out those patients whose ego struc-
tures cannot withstand the rigors of classicalpsychoanalysis or other intensive psychother-
apy. Eventually, such guidelines may form the
basis of economical systems of health care thatavoid arbitrary, clinically untenable limita-
tions on services.
A different version of this material was presented
at the American Psychiatric Association annual
meetin& San Francisco, CA, May 24, 1993. The
author is gratefulfor the encouragement and support
of the Committee on Peer Review of the American
Psychoanalytic Association Although this articlepresents some of the Committee’s work, the condu-
sions and opinions expressed are the author’s alone.
This article has not been endorsed by the American
PsychoanalyticAssociation, and it does not reflect its
official position. The opinions or o�sertions con-
tained in this article are the private views of the
author and are not to be construed as official or as
reflecting the views of the Department of the Army
or the Department ofDefense.
Gi�w 227
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
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