Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, July 18, 2015


The idea for this post is based on a post by Jim Amos, The Practical Psychosomaticist, entitled, Getting Small Again About MOC. At least, that's how it started.

Dr. Amos wrote to someone at the ABPN to find out if instead of doing PIP modules, often at substantial cost, a diplomate's use of PubMed could be tracked by the Board. He was informed that PubMed use was not an option as a PIP alternative, but that, "You have the option of seeking individual preapproval for either one (PIP) that you develop, or one that you may already be doing as a QI project in your hospital/institution."

And he was given a link to the Individual Part IV Improvement in Medical Practice Approval Request.

So I started to think about the possibility of designing a PIP for the practice of Psychoanalysis.

This is how it works:

Clinical Module: A clinical module requires that you do a chart review of at least five patients in a specific category, (for e.g., diagnosis or type of treatment, treatment setting). You must then compare data from the five patient cases, utilizing a minimum of four quality measures, with a standard specialty practice guideline. Based on the results of the review, develop a plan of improvement, carry out the plan, and in no more than two years, do a second chart review utilizing the same guideline to see if improvement has taken place. The charts may be the same or different patients but must be in the same category utilizing the same guideline and quality measures. (boldface mine)

Where do I get a standard specialty practice guideline for Psychoanalysis? I started looking online, and that's when the idea for this post changed. Because I found an Evidence Based Guideline for Psychoanalysis from BlueCross BlueShield of North Carolina.

This is a short but fascinating document. How to explain?

It has a nice, brief description of Psychoanalysis as a "procedure or service". A bit about theory, how it can be helpful, the logistics, what kind of patient is suitable for analysis, and how analysts are trained. Really quite nice.

Then it goes on to describe the "Evidence Based Guideline", and completely contradicts everything in the preceding section.

For example, in the first section, there's this paragraph:

The person best suited for psychoanalysis is one who is generally successful in most aspects of his/her life but is still unhappy. Psychoanalytic therapy is said to be beneficial for those with troubled relationships, poor self-esteem, anxiety, chronic irritability, unresolved grief, phobias, and many other conditions where they want to understand themselves and see how their own thoughts and behaviors contribute to their difficulties. Psychoanalysis is thought to promote self discovery, personal growth and development. (boldface mine)

But then, in the guideline section, it states, "Psychoanalysis is not recommended for...treatment focused on increasing self awareness, self discovery, or personal growth."

I get that they're saying self-discovery shouldn't be the purpose of analysis-not an analysis they're paying for, anyway, but really, at least change the language so it's not identical.

The guidelines are antithetical to everything an analysis is supposed to be. The "A" criteria are:

Psychoanalysis (PSA) may be appropriate if nothing else has worked.

The patient needs some kind of problem that corresponds to a diagnosis
The patient has distress in work/school/social
an ongoing disorder that requires "behavioral assessment to maintain symptom relief and/or function"
"additional treatment sessions are needed (documented by clinical evidence) to prepare for termination of therapy consisting of a clear treatment plan with well defined goals, methods and time frames to support discharge from therapy"
The patient doesn't need to be in a locked unit.

"Well defined goals, methods and time frames" in an open ended, free associative psychoanalysis. How does that work?

The "B" criteria are even worse. I'm just gonna cut and paste and highlight the phrases that particularly annoy me:

B) All of the following criteria are met;
1. There is documentation of a mental disorder diagnosis, AND

2. There is a medically necessary and documented treatment plan or updated plan
individualized for the patient with at least one of the following outcomes;

a) focuses on alleviating the patient’s distress and/or dysfunction in a timely manner, or
b) pursues achieving maintenance goals for ongoing conditions, or
c) focuses on discharge from therapy, AND

3. The individualized treatment plan includes all of the following:

a) the status of the patient’s dysfunctions being treated and documentation shows
progression toward the treatment goals, and
b) the current treatment is focused on each psychiatric symptom, and
c) treatment framework, and
d) modality of treatment, and
e) frequency, and
f) estimated length of treatment, and
g) the status of the involved family or friends in support of the patient, and
h) the status of any necessary community resources, and
i) an alternative plan if the patient does not make sufficient progress in the time frame
specified, AND

4. The treatment must be rendered by a "certified psychoanalyst" from a nationally recognized
institute for psychoanalysis.

And now my corresponding comments:

How do you define "medical necessity" for PSA?

PSA often increases the patient's distress in the short term


Focus on discharge: You better hurry up and change a lifetime's worth of patterns so we can terminate!

Status of dysfunctions?

Symptom focus? That's not PSA.

What do they mean by "treatment framework"?

The modality is PSA, duh!

You don't do family meetings in adult PSA

By their own description, PSA is appropriate for people who are generally successful. What kind of community resources are they talking about?

Define "progress"!

It sounds to me like they just took guidelines for some other kind of psychotherapy and pasted them in.

Now the worst part. The evidence.

There are 4 reference sources listed. The first is:

Dewey R. (2007). Psychoanalysis. Retrieved 7/10/2008 fromhttp://www.intropsych.com/ch13_therapies/psychoanalysis.html

This seems to be some kind of online Psychology Intro text. Psychoanalysis takes up one page. One very short page. It includes no information that would constitute a guideline, evidence based or otherwise. It describes what I consider a misinformed and outdated notion of PSA.

The second source is the "About Psychoanalysis" page on the website of the North Carolina Psychoanalytic Society. It's just a brief blurb about psychoanalysis, the couch, frequency of meeting, and the like. Nothing here in the way of guidelines.

The third source is the American Psychoanalytic Association's Standards for Education and Training in Psychoanalysis. This is a 23 page document that describes requirements for training in PSA. Like, who is eligible to be a candidate. How many case write-ups do they need to complete. It has nothing to do with guidelines for practicing PSA.

The last is the DSM-5. We'll ignore that, since it's just about diagnoses.

What we have is a completely bogus "guideline" that has no evidence base whatsoever, nothing to do with PSA, and everything to do with not wanting to cover the cost of an analysis. If you're an insurance company and you cover mental health, then you really can't afford the cost of an analysis for everyone who would benefit from one. And I guess they can't just outright state that they won't cover PSA because it's too expensive. I get it.

And in case you were wondering, this is not an out-of-date document. It was written in 2008, and reviewed in 2010, 2011, 2012, and last updated a year ago, when some (unspecified) references were removed, and others added. No changes were ever made to the guideline statement other than wording. It's up for another review this month.

I wonder if the ABPN would accept it as part of a PIP module.

Actually, the title of this post is wrong. Mr. Spock says, "Fascinating," when there's something interesting that he doesn't understand. If he does understand it, he just says, "Interesting."

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