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Volume X Publication No. 100 February, 1978

Psychotherapy and its Financial Feasibility Within The National Health Care System

Formulated by the Committee on Therapy

Group for the Advancement of Psychiatry

This publication was produced for the Group for the Advancement of Psychiatry by the Mental Health Materials Center, Inc., New York.

STATEMENT OF PURPOSE THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY has a membership of approximately 300 psychiatrists, most of whom are organized in the form of a number of working committees. These committees direct their efforts toward the study of various aspects of psychiatry and the application of this knowledge to the fields of mental health and hum an relations. Collaboration with specialists in other disciplines has been and is one of GAP's working principles. Since the formation of GAP in 1946 its members have worked closely with such other specialists as anthropologists, biologists, economists, stat1st1C1ans, educators, lawyers, nurses, psychologists, sociologists, social workers, and experts in mass communica tion, philosophy, and semantics. GAP envisages a continuing program of work according to the following aims: 1. To collect and appraise significant data in the fields of psychiatry, mental health, and human relations 2. To reevaluate old concepts and to develop and test new ones 3. To apply the knowledge thus obtained for the promotion of mental health and good human relations

GAP is an independent group, and its reports represent the composite findings and opinions of its members only, guided by its many consultants. PSYCHOTHERAPY AND ITS FINANCIAL FEASIBILITY WITH11'," THE NATI0J',"AL HEALTH CARE SYSTEM was formulated by the Committee on Therapy which acknowledges on page 11 the participation of others in the presentation of this report. The members of this committee are listed below. The following pages list the members of the other GAP committees as well as additional membership categories and current and past officers of GAP. CoMMJTrEE ON THERAPY

William Offenkrantr, Chicago, IL, Chairman Henry W. Brosin. Tucson, AZ

Eugene ll. Feigdson, New York. NY Peter H. Knapp, Boston. MA Robert Michels, New York, NY Andrew P. Morrison. Cambridge, MA

Fra nz K. Rcichsman, Brooklyn, N Y Lewis L . Robbins, Glen Oaks, N Y Allan D . Rosenblall, L a Jolla, C A Justin Simon , Berkeley, C A Joseph P . Tu pin , Sacra mento, CA CO!I.D,l !Trl::f.: os A uo 1.F.SC[NC►: Warren

Cadpaillc, Englewood , CO,

Chairman

Maurice R. Frie nd, :'\e1s York, N Y Charles A . :V!alonc, Cleveland, O H Derek �-t iller, Chicago, ! L S ilvio J . Oncs1i, J r. , lldmont, �1A

Prescott W. Tho rn µso 11, San Jose , CA Chairman Gene D. Cohen, Roc k vi lle, MD Charles YI. Gait:,., Houston, TX Lawrence F. Gree nleigh, Los Angeles, CA :'v!auricc [. Linden , Ph,laddphia, PA Robert D. Patterson, l .c::-x ington, M A F.ric Pf'eiffer , Denver, CO F. Conyers Thompson, J r . , Atlanta, GA Jack Weinberg, Chicago, 1 L C<H.t MITTt::t o.-.: C H n.n PsvcH tATR\' Joseph Fisc hhoff. Detroit , �1 1 .

Chairman

Paul L. Ada ms, Louisville, K Y J:: . Jarnes A nthony, SL. Louis, \. ifO Ja mes M. Bell, Can aa n , :'\ Y H a rold Donald Dunton . :-- e w Yo rk, t\' Y Joseph M . Green , Madi,on, W I John F. Kenward, Ch icago, l l. Ake Mat�«on. Pittsburgh. PA John F. McO,:rmott, Jr., Honolulu, H I TT,codorc Shapiro, :'-lew York. N Y Exie E . Welsch , New York , N Y Virginia N . Wilking, New York , ,'i Y C0"1MlTTEE ON THE Cou.F.(:r: STv 1a.s·r Ma lkah Tolpin Notman . Brookli ne, M A , Chairman Robert L. Arnstein, Hamden , CT Ha rrison P. F.ddy, New York. N Y

C. Knigh1 A1uncn , Cbarlot.1.esville, VA Lee B. Macht, Cambridge, \1A H erbert C. Modlin, Topeka, KS John C. i\ emiah, Boston, MA A n thony F. Panze1ta, Philadel phia, PA John J. Schwab, Lou isville, K Y John A . Talliot, New York, 'J V Charles B. Wilkinson, Kamas City, M O

Varda Peller Ganz, La.Jolla, CA Myron B. Liptzin, Chapel Hill, l\C Gloria C. Onque, Pittsburgh, PA Elizab�th Aub Reid, Cambridge, \.I A Kent £. Robinso n , Towson, M O F.arle Silber, Chevr Chase, M D Tom G . Sta uffer, White Plains, N Y

Harold I . Lief, Philadelphia, PA Herbert Parde,, Englewood, CO Jeanne Spurlock, Silver Spring, MD llryce Templeton. Philadelphia, Pi\ Sidney L. Werkman, Denver, CO Sherwyn M. Woods, Los Angeles, CA

Co�L\.IJTn:t: ON THI•: rA�Hl. \'

Allan Reigel, Tuc son, AZ, Chairman Mary Am, B. Banusis, Ph iladelphia, I',._ W, Walter \1enninger, Topeka, KS Eugene M. Caffey, Jr., Washington, DC Merrill T. Eat0n. Omaha. N il Joseph T . English, New Yo rk, NY Jame, B. Fun khouser, Richri1ond, VA Robert S. Garhcr, Belle Mea d, NJ Alici.i Gavalya, Allston, MA Donald J. Scher!. Boston, MA Herzl R. Spiro, Milwaukee, W I George F . Wilson, Belle Mead, "IJ Jack A . Wolford, Pittsburgh, PA

Peter BrowninR Hoffman. Charlo11esville, VA, C hairman Edward I. Auer, Philadelp hia, PA Elissa P. Benedek, A nn Arbor, M J Joh n Do nnellr, Ha rtford . CT Carl P. Malmquist, Minneapolis, M N A. Louis Mcl;arry, Floral Park, N Y Sey mour Pollack, Los Angeles, CA Jonas R . Ra ppeport, Balti more, M D Loren H . Roth, Pi t1sburgh, l'A

Co MMtTrfE ON \1 Er-.-T�1. RETA Ro.-. -rroN

Robert N. Butler, Washington, or.,

rhomas G. Webster. Washingwn, DC, Chairman Howard V. Bair, Parsons, KS Norman R. Bernstein, Boston, '.\-iA Leo Madow, Philadelphia, PA Carol )' n B. Robinowit,, Bethesda, MD George Ta,j a n , Los Angeles. CA Warren T. Va ughan, Jr., Portola Valley, CA He nry H. Work, Washingwn, DC

Paul Chodoff, Washingltln, DC Jerome Frn nk, Baltimore, �1D J udd M,mn or, Los A ngeles. CA Montague Ullman, Ardsley, N Y

Joseph S;t l l t:n, San Francisco, C A ,

Chairman

C. Christian Be�ls. New York, N Y

Ivan Boszorm enyi- �agy, \Vyncmc, P A Murray Bowe n , Chevy Chase, :VI l) Henry U. Crunehau m, Cambridge, \IA :Vlargaret �1 . Lawrence, Pomona, 'i Y David \.l endcll, H ouston, TX Carol Naddsou, Boston, �1 A Norman L. Pa ul, Boswn, MA CoM!\t rrru: ON Govr.nN M f.!'ffAL Act::-.:uts Si<lney S. Goldenso h n , Ja maica, '.\: Y, Chairman William S. Allenm, , Richmond, VA Allic1 1 \{. B iele, Ph iladel phia, PA Roger Peele, Washi n�ton, DC �arviu E. Perkins, \Vhitc Pl.a i ns, :',J Y Harvey L. P. Resni k, College Park, \1 D li an-ey I ee Ruben, New H aven , CT William W. Van S1one, Palo Aho, C:\

Brya n t \.1 . \\ edge , Washingto n , DC, Chai rman r'rarn:is F. Barnes, Chevy C h ;1st"., �1 D Alcxande,· Gralnic k . Pon Chester, :\' Y John E. Mack, Chestn ut Hill . :VIA Rita R. Rogers , Torran ce, CA Bertram H. Schaffner. :--.e w York, :-J Y Monra m P. Tone, Ne \\' Orle�rn"i, LA Roy M. Wh1tman, Cinci nnati, OH C0.\1 Mf'ITl-:E O!\: �•l f.t> I C A L tnCCr\TlON Paul Tyler Wilso n, Bethesda, M D , Chairm an D;,virl R. Hawkins, Charlo11e.s villc, VA

COMMITTSS ON MENTAi. H •.s l.TH SERVI CES

Co,.1M 1TTEE o,..., PREVE:--:Trvt:: PSYCHIATRY Ruth W. Lidr., Woodbridge, CT, Chairman Charles \.l. B ryam, San Francisco, CA Jules V. Coleman, New H;ivcn, CT Stephen Fkck, Ne" H aven, CT Frederick Gottlieb, Los Angeles, CA E.. James Lieberman, Wash 111gton, 0C Ri<l1 ard G. Morrill, Boston, M A Harris B. Peck, Bronx, N Y C:O!\OflTTEE O N PSYCH IATRY ANO COMM U N fTY Alexander S. Rogawski, Los A n geles, C A ,

Chairman

COMM ITTl::t:: ON PsvcHJATflY A N U LAw

C0 /\·1 MITTE.� ON PS\'CH IATIO' 1\1\' 0 POLITICS

Chairman

Alben .) . Lubi n, Woodside. C A , Chairman

Sid ney S . f'urst, Bronx, '.'/ Y Richard C . Lewis, Nt,w Haven. CT Mortimer Ostow , Bronx. :'\ Y Mich;i�I R . Zales, Gree nwich, CT Co:-.t M1rn::1:: 0:"-1 P s ·t "CHI.-.TRY 1:--i l N O t'STRY Duane Q. Hage n , St . Louis, MO, Chairman

Barrie S . G,·ci ff, Boston, MA R. Edward H u ffman, A,h eville, N C Herbert L. Klemme, Stillwater, \,f N Alan A. :vlcLcan, New Yor k , N Y fl,1 Vid E . Morrison, Topeka, KS Clarence J . Rowe, St. Paul, MN John A. Turner, San Francisco, CA John Wakefielrl, San Jose, CA.

COM MITTEE

ON PSYCHOPATHOUJGY

Charles Shagass, Philadelphia, PA, Chairman Eric A. Baum, Gainesville, Fl. Wagner H. Bridger, Bronx, NY Paul E . H uston, Iowa City, IA Richard E. Renneker, Los Angeles, CA A. Joh11 Rush, Oklahoma City, OK

Robert J. Campbell, New York, NY, Chairman James A. ·K night, New Orleans, LA Norman L. Loux, Sellersville, PA Mildred Mitchell-Bateman, Charleston , WV Mabel Ross, Chicago, IL Julius Schreiber, Washington, DC Robert H. Sharpley, Cambridge, :VIA Miles F. Shore, Boston , M A Robert A . Solow, Beverly Hills, C A Ken t A. Zimmerman, Berkeley, CA COMMITI"H ON

RESEARCH

A l fred H. Sta nton, Wellesley Hills, MA, Ch airman John E. Adams, Gainesville, FL Robert Cancro, New York, N Y Stanley H . Eldred, Belmont, MA John C. Gunderson, Belmont, MA Jerry M. Lewis, Dallas, TX Morris A. Lipton, Chapel Hill. NC John G. Looney, Dallas, TX Ralph R. Notman, Brookline, M A Charles P . O'Brien, Philadelphia, PA John S. Strauss, New Haven, CT Gene L. Usdin, New Orleans, LA Herbert Weiner, Rronx, NY COMMITl"EE ON SOCIAL ISSUES Roy W. Menninger, Topeka, KS, Chairman Viola W. Bernard , New York, NY Roderic Gorney, Los Angeles, CA Lester Grinspoon 1 Boston, MA

Jod S. H andler, Evanston, I L Perry Ottenberg, Merion Station, PA Kendon W. Smith , Piermont, NY

COMMITTEE ON THERAernnc CAiu: Thomas E. Cunis, Chapel Hill, NC, Chairman Bernard Bandier, Cambridge, MA Andrea K. Delgario, New York, NY Robert W. Gibson, Towson, MD Harold A. Greenberg, Silver Spring, MD Donald W. Hammersley, Washington, DC . A Roberto I.. Jimenez, Newton Cent.er, \1 Milton Kramer, Cincinnati, OH Orlando B . Lightloot, Boston, MA Melvin Sabshin, Wa,hington, DC Benjamin Simon, lloston, MA Robert E. Switzer, Trevose , PA CONTRIHl.;TJ NG MEMHf.RS Carlos C. Alden , Jr., Buffalo, N Y Charlotte C. Babcock, Pittsburgh, PA Grace Baker, :-lew York, NY Walter E. Barton, Hartland, VT Spencer Bayle,, Houston, TX Aaron T. Beck, Wynnewood , PA Anne R. Benjamin, Chicag<J, I L Sidney Berman, Washington, DC H. Waldo Bird, St. Louis, MO Wilfred Bloomberg, Cambridge, MA Thoma"s L. Brannick, l mola, CA H. Keith H. Brodie, Durham, N C Eugene Brody, Baltimore, M O Ewald W. Busse, Durham, N C Dale C . Cameron, S a n Diego, CA Ian L. W. Clancey, Ontario, Canada Sanford I. Cohrn, Boston, MA Robert ('..oles, Cambridge, MA Frank J. Curran, New York, NY William D. Davidso n, Washington, DC Leonard J. Duhl, Berkele�·. CA Lloyd C. Elam , Nashville, TN Louis C. English, Pomona, NY Dana L. Farnsworth , Belmont, MA Stuart M. Finch. Tucson, AZ Alfred f'larsheim, Chicago, I I. Archie R. Foley, New York, N Y Alan Frank, Albuquerque, N M Daniel X . Freedman, Chicago, I L Albert J. Glass, Sau Francis<:0, C A Louis A . Gottschalk, Irvine, CA Milton Greenblatt, Los A ngeles, CA Maurice H. Greenhill, R y e, NY

John H. Greist, Indianapolis, ( :\'. Roy R. Grinker, Sr., Chicago, IL E rnest M. Gruen berg, flal1.i rnore, M D S�an ley Hammons, Tuscal oosa , A L Edward 0 . Harper, Cleveland, OH Saul I . Hanison, Au n A 1 bor, Ml Mary O"Neill Hawkins, New York, '.'/Y .J. Cotter �lirsd1berg, Topeka, K S Edward J . Hornick, /\ c w York, :-I \' Joseph H ugh es, Philarielphia, P.� Ponia Bell Hume, l\er keley, CA Benjamin Jeffries, Harper Wood,, :½1 Irene \I. Jossel y n , Phoenix, AZ Jay Katz, :\e,v J·laven, C.T Sh eppard G. Kellam, Chicag·o, I L Donald F . Klein. :--J e w York, :,,; y Gerald L . Klerm a 1 1 , Boston, :VI A Othilda M. Krn1s, Cincinnati, OH John P. Lambert, Kato nah , NY Zigmond \-1. Lebrnsnh n . \Vashington, nc Henry D . Lederer Washington, DC Robert L. Leopol d , Philadelphia, PA Alan I. Levenson , Tucs o n , AZ Earl A . Loomis, Jr., Greenport. NY Reginald S. Lourie, Chevy Chase, MD Alfred 0. Ludwig . Boston, MA Jept:ha R. :V!acFarlane, Carden City, N Y John A. Macleod, Cincinnati , OH Signcy C . Margoli n , Englewood, CO Peter A. M,i rtin, Southfield, \1 1 Jack H . Mendelson, Belmont, MA Karl A. Menninger, Topeka, KS Mary E . Mercer, Nyack, N Y Eugene Meyer, Baltimore, MD James G. \f iller, Louisville, KY John E. :-lardini, Bethesda, MD Peter R . Neubauer, New York, N I' Joseph D. /\oshpirz, Wash irq,(t.0 11, DC Lucy D. Oza rin, Bethesda, :vi o Bernard L. Pacella, '-iew Yor k, '.\I Y Willia m L . Pel tz, Manchester, vr Irving Philips, San Fra11cisco, CA Charles A. l'i11derhughes, B e d ford , \IA , . Rexford, Cambridge, M .� Eveoleen '\ Milton Rosenbaum, Bronx, NY W. Donald Ross, Cincinnati, OH Le., ter H . Rudr, Chicago, IL Ceorge E. Ruff, Philadelphia, Pi\ David S. Sanders, lleverly Hills, Ci\ Kurt. 0. Schksinger, San Francisco , CA I

Robert A. Senesrn , AlbtH.Ju crquc, N M Calvin F . Se ulage, Sa11sali10, CA Richard l . Shad er, Ncw1.nn Cen<cr, M ;\ Harley C. Shands, "' "w \"ork . :-JY Alben . l Sil verm a n . Ann Arbo,·, :-f l Benson I{. Snyder, Ca mbridge, \·1 i\ Joh n P. Spief:�l. Walth a m , \! A Brnndt F. Steele, Denver, CO Eleanor ,.\. Steele, I len vt:r. CO Rutlierfo, d B . Stevens, l\ew York , N Y A l a n A . Stone, Ca mbridge , M A Perry C . Talkington, D rt l l > <, TX Gra h a m C. Ta)•lor, \lontr cal . Canada Lloyd .J . Thompson, Chapel H i ll, ?\C ! fa n·ey J Tompki n., , Ne-, York. C\Y Lucia E. Tower, Ch icago, 1 1 . Suzanne T. \'an A rnc-rorq{<�ll , Cambri dge , M A Robert S. \V allerstrin , San Francisco, CA Andrew S. \Va[�on , A n n 1\ rb nr , \1 f Edward M. \.Vei nshel, S a n F ranc i�co, CA . fo.s oph B , Wheelwrigh t, Kenrfield, C.A Robert L. Williams, Ho ustn 1 1 , TX Ronald M . Wintrob. Farmingt.rm, CT 3ta nley F. Yolles, Stnnr Bmok, N Y Israel Zwerling, Phil;1delphia, PA

S. Spafford Ackerly, Lo uisville, K Y Ken11eth E . A ppel, Ardmore. PA Leo H. Barterncier, Balt.irnore, ,1 D l \'an C. R erlir.n, Coral Gables, FL 0. S purgeon English, Narbert h , PA Marion E. Kenwort h y , New York, "i Y Benjamin S i mon, l\ os ton, \.fA F,·anl'.is A. Sleeper, Cape Elizab,·th, \.I E l . I F'F. Co;-.;s1:1.TA :,.J1'

Mrs. Ethel L. Ginsburg, New Yor k , NY

BOARD OF DI R ECT ORS Officers President Jack A. Wolford, \.f.D. 38 1 1 O'H ara Street Piusbu rgh, PA 1 5 2 6 1

COMMITTEE ACKNOWLEDGMENTS John Donnelly George Tarjan Judd \,!armor

Vice President Robert W. Gibson. M.D. Sheppard and Enoch Pratt Hospital Towson, MD 21204

1969- 71 1971-73 1973-75

For their assistance in the formulation uf this repoi-t, the Committee on Therapy wishes to acknowledge the contributions of cwu consultants, Frank SuHivan, :\1.D., Chairman, Comrni.s sion on Standards of Practice and Third-Party Payment. Arnerican Psychiatric Associat!on, and Evelyn \1yers, M.A., Coordinator, Psychiatric Care Insurance Coverage, American Psychiatric Association Also helpful in the preparation of this document were GAP Fellows, Richard Ferre, M.D., and Peter Panzarino, M.D.

Deceased Past Pruidents \Vil1iam C. Menninger Sol W. Ginsburg

Secretary Henry H. Work, \1.D. l 700 EighLeenth Street, N. W. Washington, DC 20009 Treasurer

C.hairman

Leo Madow, M.D. 3300 Henry Avenue Philadelphia, PA 19129

Merrill T. Eaton, \1.D Nebraska Psychiatric I nstilute 602 South 45th Street Omaha, r--:I\ 68106

J mmcdiate Past President

C. Knight Aldrich Margaret M. La,,:rence Carl P. Malmquist Carolyn B, Robinowltz Robert A. Solow Alfred H. Stanton

John C. �emiah, M.D. 330 Brookline Avenue Boston, MA 02215 Boa.rd A1 embers

Consu/J,a.nl\

Paul Chodoff Mildred Mitchell-Bateman Rita R. Rogers Miles F. Shore

John C. Ncmiah Melvin Sabshin Ex Officio

Past Presidents, Ex Officio Jack R. Ewalt Walter £. Barton Dana L. Farnsworth Marion E. Kenworthy Henry W. Brosin Leo H. Bartemeier Robert S. Garber Herben C. \,fodlin

I 94&--51 1955-57

1951-53 1953-55 1957-59 1959-61 l 961-53 1963-65 1965-67 1967-69

Jack A. Wolford Robert VI'. Gibson Henry H. Work Leo Madow MARKETJNG BOAKO

Miles F. Shore, Chairman Robert J. Campbell Carl P. Malmquist Robert A. Solow

Psychotheraf>y within the national health care s;�·tem

States developed outside the mainstream of medicine, in close association with the development of prisons, alms houses and orphanages. 1 Long before this, however, the exclusion of the psychiatrically ill from health care systems had been rationalized for centuries, beginning with biblical references to the mentally ill as being possessed of demons. This exclusion resulted from the same motive that has ex cluded patients suffering from alcoholism; both types of illness have been perceived as the consequence of moral deficiency. Furthermore, the development of the existing bio-medical models of illness, being entirely biochemically oriented, was incapable of including psychological or social factors in the genesis of disease. 2 While a bio-psycho-social model has been actively proposed for decades, most recently by Engcl3, it has yet to become the general conceptual framework of physicians; only a few of whom have gotten away from the reductionism and dualism of the present "medical", i.e., purely bio-medical model. Considering the nature of this model, we can understand the misgivings of many in the medical profession about psychotherapy. The humanitarian issue is further complicated by the fact that psychotherapy is often prescribed for patients whose distur bance is not publicly apparent to an observer who is not aware of the patient's private suffering, or the toll inflicted on his children, spouse or colleagues. The distributive social justice arg·ument is that the poten tial for personal freedom and the pursuit of happiness should be distributed as equally as possible; and if some are impaired in this regard as a consequence of illnesses that can be alleviated by psychotherapy, society has an obligation to provide that treatment so that all will have a more equal opportunity in life, just as it has an obligation to provide treatment for other disabling conditions. The utilitarian, cost-benefit argument is that for certain groups of patients this treatment, however much it costs, is

lntroduction

less costly than any available alternative. The (more expen sive) alternatives include lengthy or repeated hospitalization, the increased incidence of physical illness and disability, and the social sequelae of untreated or inadequately treated men tal illness-diminished productivity, broken families, dis turbed children, crime, etc.

Dtfinitions

DEFINITIONS

Psychotherapy has been defined as ... a developing rransar.1 ion berween two people, one suffering from .. distress or exhibiting disordered behavior, the other offering amelioration as [a] professional activity. The transaction is structured and prngramrned by culture, as well as influenced by the individual histories and personalities of both participants.• Amelioration µr·esumes chang-e . . [ai1d} bearing on this broad general aim are certain common assurnptions. The first is a (humanitarian} assumption about the desirability of change, namely, that subjective distress and certain forms of deviant behavior nor only car� be ameliorated bur should be. Second, that a learning or developmental difficulty has played a [causative} role in Lile patient's disturbance. Third, that this [disturbance or distress] is c:orrenable by relearning. Fourt.h, is an assumption about the relevance of human relar.ionships, both in giving rise lO 1he defect and in remedying it, namely, that the therapeutic relationship will it.self he helpful. ... '

This relearning occurs with varying proportions of insight, conditioning and corrective emotional experiences, depending upon the specific form of psychotherapy. Three dimensions: "depth," length of treatment and fre quency of sessions help to describe various types of psy chotherapy. Depth means the extent Lo which the therapist tries to explore the patient's attitudes and feelings LhaL have been excluded from conscious awareness. "Deep therapy" is synonymous with exploratory, and usually with long-term intensive, psychotherapy, and includes psychoanalysis. The latter is a lengthy (three-five years), frequent (three-five times per week), therapeutic process, with each session lasting 45-50 minuLcs. It is characterized by two phases. In the first l6

of these, the patient reacts to the intentional ambiguity with which the treatment is organized with an effort to com prehend his relationship with the analyst and achieve gratifi cation from him by methods he has used in the past. This makes "the here and now" experience between patient and therapist a vivid human situation that reveals the ways in which past conflicts are still active in the patient's current perceptions and behavior. A common concern about this form of treatment is that it induces an unnecessary and deleterious dependency rela tionship as a consequence of this first phase. Actually, the task of the second phase is to enhance the patient's autonomy by helping him grasp the ways in which the present is differ ent from the past, and the reasons for his wishing ro cling ro the past. By contrast, therapies ranging from less exploratory to completely supportive do not aim to alter habitual modes of coping or underlying basic conflicts within the patient's per sonality, but rather to strengthen those existing mental func tions that are adaptively more effective, so as to enable the patient to cope more successfully with whatever inner or outer stress gave rise to his problems. Such therapies are in no way less valuable than therapy that explores conflict5 which are less accessible to awareness; the terms are sche matic and descriptive, not evaluative. This form of therapy often works through a corrective emotional experience and conditioning that occur when the patient is able to experience and express previously unac ceprable feelings in the presence of a benign authority figure (the therapist). This results in a rise in self-esteem that is rc-inforced when the patient also expresses these feelings outside of trealrnent and finds that his fears are not realized. This form of treatment usually docs not involve insight into the patient's past or his unconscious mental life. For purposes of this report, treatment extending for more

, 18

Psychotherapy within the national health care system

than 50 sessions or lasting longer than 12 months, will arbi trarily be defined as "long-term." Although intensive, explor atory psychotherapy, of necessity, is always long-term, often, the longest of long-term therapy is supportive and usually infrequent, i.e. two to four sessions per month. The goal of such supportive therapy is usually to help the patient cope with an unstable situation and the prevention of deteriora tion in chronically ill patients. It is in many ways analogous to the chronic use of insulin in the maintenance therapy of diabetic patients.

3 ILLUSTRATIVE CASE EXAMPLES

Four clinical examples follow. The first two are examples of brief psychotherapy, the second two are of long-term psychotherapy. All illustrate the mingling of supportive and exploratory strategies in therapy, but the third case is primarily an example ofl ong-term supportive treatment and the fourth of exploratory therapy. The principal differences are in the way the therapeutic relationship is utilized in the treatment.

Case #1 A young married woman was referred to a psychiatrist by her internist, who failed to find any physical causes for re current headaches which had begun during the second year of her three-year marriage. The psychiatrist quickly sur mised and shared with his patient the observation that the headaches always followed occasions of feeling irritated or mistreated by her husband, but that she had internal injunc tions against expressing these feelings. Armed with this in formation and emboldened by the tacit consent of the psy chiatrist, she successfully experimented with more direct modes of expression, thereby informing her husband of behavior of which he had been unaware. Improved com munication in the marriage ensued, the headaches disap peared, and a course of brief treatment was successfully ended. This is an oversimplified but not an uncommon clini cal history for patients who demonstrate relatively cir cumscribed symptomatology and flexibility of responses. 19

Psychutheraj)y within the national health care system

Case #2 An even simpler example of altering the balance of mental organization is seen in the case of an eighteen-year-old high school senior who suddenly became withdrawn from his fam ily and friends and developed symptoms of anxiety, insom nia and nightmares. He had secretly become involved with an older woman and, in response to her urging and teasing, had experimented with certain illicit drugs and associated with a delinquent social element engaged in borderline crim inal activities. Initially, he felt pride in this sexual adventure but later trapped by it and by the threat of seeming ridicu lously juvenile if he expressed any of his reservations. Nor could he discuss his dilemma with anyone. An astute teacher noticed the boy's sudden onset of distractedness in school, sensed his discomfort, and tactfully suggested he consult someone at the local mental health facility. Out of despera tion, the boy took the advice. When after a few meetings he felt it was safe fully to unburden himself to the psychiatrist, he did so. In the very process of telling the story, not only did his self-esteem rise, but it also became clearer to him what the issues were underlying his dilemma. Thus, by the time he came to the critical question: "What should I do?" the therapist had only to point out that he already seemed to have decided. Thereby, the therapist lent his support to that decision which brought the boy back into harmony with his own internal standards of behavior and helped him avoid moralistic self-recrimination about his temporary fall from grace. Simultaneously, the symptoms disappeared. This re sponse confirmed the psychiatrist's initial diagnostic impres sion of a Transient Situational Disturbance which could be dealt with on a brief, supportive basis.

Case #3 A thirty-year-old welfare rcc1p1ent, an unemployed car penter, had spent two of his last five years in numerous

Illustrative case examples

admissions to various state mental institutions. He had be come psychotic after his wife ended their brief and stormy _ marriage. Between hospitalizations he had drifted up and down the West Coast, occasionally working, drinking too much, and often on skid row. During his last hospitalization, a psychiatrist began psychotherapy and was impressed not only by the patient's motivation to get better, but also by his capacity to become involved in a working relationship with the therapist-strengths in this man's battle against his severe mental illness. The patient was the only son of a strict fundamentalist preacher, and he had been raised to follow in his father's footsteps. Early in his adolescence, he began to experience g:eat difficulty in containing either his resentment against lus father's untempered harshness or his own intrusive sex ual fantasies. Through rigid religious obedience, daily ritualistic prayer, study and physical exert.ion, he managed to get by. At the earliest possible moment he fled into a mar riage to a demanding, cold and ambitious woman, but the ·marriage was a disaster. Immediately after his wife left him, he became drunk, went to a prostitute for the first time in his life, and then became psychotic. His first hospitalization lasted over a year, and thereafter he could not long remain out of an institution without again confronting the forbidden perils of freedom. Although un able to face going back home, his relationships were always patterned by the search for an older "protector." He either found a religious figure who enjoined him to a faith and celibacy he could not maintain, or else he found a "liberator" who attempted to loosen his sexual constraints. Both roads led back to the hospital. The psychiatrist through his clinical understanding was able to steer a course b-etween bor.h hazards. By being directive with patient firmness instead of harshness, the therapist was able to help the patient re establish communication with his familv and to learn that his

Psychotherapy within the national health care system

father was more tolerant and understanding than he had been or had seemed during the patient's earlier years. In the setting of the therapeutic relationship, a schedule of psy chotropic medication was prescribed and maintained for the first time. After a year of weekly therapy meetings (with occasional extra sessions for emergencies) the patient's self image as incurably insane became modified by the experi ence of his longest period out of a hospital. Subsequently, he entered a vocational rehabilitation program to become a welder. He continues to see the psychiatrist once a month and calls for extra sessions whenever something unusually stressful occurs. The sexual conflicts were tactfully discussed over a period of time, but were essentially let alone. The patient came to accept the fact that occasional masturbation was a psychological and physiological necess ity, and that without that outlet, he could expect terrifying erotic night mares. In time, perhaps, he will marry again, the only course which will afford him any alternative sexual gratification acceptable to the religious convictions which r emain a source of great stability, reassurance and solace. No short course of treatment could have accomplished these goals and without this therapy the probability is that this man would have deteriorated into a chronic psychotic alcoholic, a lifetime ward of the state, living a wretched, narrow exisr.ence between whorehouse and hospital. This case also provides the backdrop against which to speak once again to the paradox that long-term intensive psychotherapy is generally not for the most seriously ill, except in the hands of a relatively small number of specially trained clinicians whose practice is devoted almost e ntirely to this type of patient. Exploratory, "depth" psychotherapy might have in creased the risk of another psychotic episode for th is man. Again, the position in this report issues from a pragmatic as well as a theoretical point of view: long-term therapy is

Illustrative case examples

indicated only when a successful, enduring result cannot be achieved with briefer therapy. ;\J°ext we turn to a particular form of long-term intensive, individual, outpatient psychotherapy: psychoanalysis.

Case #4 At thirty-five, Mrs. T. was, to all external appearances, the very model of success. She was the beautiful mother of two beautiful daughters, the wife of a successful professional man of rising prominence. She had graduated with honors from a fine school, and although she had begun graduate school in architecture, she forsook career plans in order to marry and to raise her children. Sexual problems were man ifest early in the marriage, but her husband took an under standing view of her lack of sexual desire, and over the ten years of their marriage infrequency of intercourse became an accepted fact about which little was said and nothing done. In the second and sixth years of the marriage, shortly after the birth of each child, the patient became severely depressed. However, her husband became concerned only when the second child was a year old and his wife expressed suicidal ideation, confessing that for the previous year she had been consuming a pint of whiskey each afternoon before their regular late afternoon cocktail. At his insistence she consulted a psychiatrist who saw her once a week for three months with marked symptomaric relief. However, she stopped treatment when she began to feel better, and her hus band did not insist that she continue. Over the next two years the husband took on additional committee work which even further diminished the time he had available for his family. The patient's drinking increased, and she became more irri table with her children, especially with the older daughter. Over that period of time she turned the care of her children

Psychotherapy within the ·national health care .1y:,tem

totally over to a live-in housekeeper and began an affair with a friend and colleague of her husband. When the affair came to light, her husband was "hurt" but "forgiving.'' That is, he did not respond with jealous concern or even anger as she had hoped he would. That night she attempted suicide by an overdose of sleeping pills. During four consultative interviews, the Lreating physician ascertained that psychoanalysis was indicated. 6 During the course of a psychoanalysis that required four sessions each week over a period of four and a half years, the patient learned that since childhood she had remained locked in battle with her mother and brother over the affections of her remote, emotionally isolated father. Mother was a depressed, bitter and verbally abusive woman who had been pushed into marriage by her socially prominent family when she became pregnant with the patient's older brother. The brother was a handsome, charming, spoiled child who excelled both scholastically and artistically without apparent effort. He was the favorite of both parents, and the patient's only method of gaining her father's attention was through teasing or mis behavior. Her husband was unlike her father in being kind and forgiving, but resembled him greatly in the emotional remoteness which characterized all his extraprofessional interests. The course of the treatment followed a sequence of be haviors thaL recapitulated her most significant early-life experiences within the therapeutic relationship. At first, she was coy and competitive with the therapist, as she now realized she had also been with her first Lherapist, her hus band and her father. Then, as a result of this regression to an earlier-life mode, she realized Lhat the pasr was indeed "alive in the present" in the therapist's consulting room, and that her provocative behavior defended her against. her still in tense longings for her father's love and approval. Eventually, she came to grips with her famasy that her

,. .

I llustra.tive wse exarnj;les

father, and now the analyst, failed to meet her needs only because he was afraid of his wife's anger, As these feelings emerged in the relationship with the therapist, they were spontaneously followed by early memories which confirmed the existence of the fantasy that she indeed had been special to her father as she now hoped to be to her therapist. She became aware that her depression after the birth of each of her children and later her suicidal attempt resulted from anger at her husband's lack of responsiveness and the pain of having given up her own career for him. This re-awakened similar feelings of helpless anger and depression al her father who had remained aloof despite her craving for his affection. After these issues came into focus in the treatment, she could come to grips with her past and present feelings of unworthiness. These came to be understood as the result of guilt of which she had not previously been aware, because of her rage at her unfulfilled longings toward her father and husband in the past and therapist in the present, as well as of guilt she felt toward her depreciated mother. Finally, she achieved some objectivity in this regard and was able to reassess her mother in the light of the mother's life situation at the time the patient was growing up. This resulted in her gaining a measure of tolerance, forgiveness and resignation with a new awareness of the underlying bond of affection between them.. Long before these insights were fully integrated into conscious behavior, however, and while the patienL was still Lhoroughly miserable inside the consulting room, she developed a sense of responsibility for herself and an increased capacity for dealing with the manv difficulties in her life outside the consulting room. As in th� far simpler case of the young wife with headaches, some difficult issues in the marriage had to be exposed and faced both by the patient and by her husband. He Loo had to Lake responsibility for the ease with which he had allowed serious

Psychotherapy within the national health care system

problems to go unattended under the guise of "kindness and understand ing." A common misconceptio n about this type of treatment 1s that the goal is to uncover an original, historical "trauma," the "why" of a behavior, with the implication that this dis covery is curative. It is not. Rather the patient's experience and understanding of how the past is alive in the present, and the investigation of why the patient wants to keep it that way are the essential factors.

4 RESULTS OF RESEARCH ON THE EFFECTIVENESS OF PSYCHOTHERAPY

Psychotherapy research has been a field of intense activity and controversy with tho usands of published papers. While the effectiveness of different treatment approaches is a central issue in this research, much of it extends toward the question of how treatment works, and to methodologic problems rather than to the measurement of results. This brief overview focuses only on research concerning the effect of psychotherapy. The recent history of the field dates from a review by H.J. Eysenck in 1952 which co ncluded that psychotherapy was an ineffective form of treatment. 7 Eysenck concluded that as many patients recover· from psychiatric symptoms without treatment as with it. While Eysenck's methodology has been extensively criticized, it must be acknowledged that the topic is f sufficiently complex that it is dif icult not to order the data so as to support the previous orientation or theoretical prefer ences of the invesligalor. In any event, there is a great deal of research now which supports the notion that psychotherapy works, thanks in part to Eysenck's early nihilistic challenge. One of the central flaws in Eysenck's revie,v was his accept ing as a measure of "cure" the patient's subjective statement of symptomatic improvem ent, neither looking at the nature of the improvement nor re-examining the patient at a later date to assess the durability of the change. The phenomenon of improvement without treatment is a real and important one if the effect of psychotherapy is to be separated from the mere passage of time. Sifneos and col leagues found that patients who are randomly assigned to a 27

Psychotherapy within the national health care system

waiting list report moderate symptomatic relief before treatment starts, but no psychodynamic change in conse quence of the passage of time alone. After treatment, the majority of patients show some resolution of emotional con flicts, improved self-understanding, new learning, and the acquisition of problem-solving abilities, whether or not they waited before treatment began. 8 · Investigating the same problem from another point of view, Malan and his associc ates found that a group of patients who appeared dramati cally improved without treatment, when studied more closely, in fact had had a striking therapeutic response to a single interview and actually demonstrated the occasional efficacy of extremely brief psychotherapy. 9 The role of psychotherapy in the treatment of hospitalized schizophrenic patients has been another subject of research. May and co-workers first found that psychotherapy was of minimal value, 10 but Karon and Vandenbros offered evi dence that these conclusions were related to the work of inexperienced therapists. They showed that when experi enced psychotherapists conduct the treatment, the course of illness is significantly altered. Patients who were treated by experienced psychotherapists not only spent less time in the hospital during the initial period of acute illness, but also spent roughly half as much time back in the hospital during two years of follow-up.11 Karon further reports a review of other psychotherapy re�earch with regard to whether experienced or inexperi enced therapists were used i11 the research project. He con cludes: "In every study where psychotherapy has not been helpful, quality control of relevant training, experience, and motivation ( of the treating psychotherapist) has not been maintained." 12 The most comprehensive answer to the question of whether psychotherapy works should emerge from the studies of those who review the vast literature on the subject.

Research on effectiveness of psychotherapy

However, at least one team that has undertaken such a re view is extremely cautious in drawing any conclusions. Ber g·in and Strupp after reviewing over 2,000 papers, sum marize their disappoimment: Research in psychotherapy has failed to make a deep impact on practice and technique, presumably, because the results of most investigations have not had substantial practical significance. Reasons for this lack include the relatively short period or time systematic research has been focused on the problems of psychotherapy, deficiencies in techniques avail able to the researcher, and practical difficulties in designing and carrying out adequately controlJed studies. Most re searchers have been faced with serious limitations in collect ing and analyzing data from representative samples of patients and therapists. Follow-up studies have been difficult to carry out; the crucial requirement of enlisting the full cooperation of therapists, patients, and institutions has been a continual stumbling block; and in general, rigorous designs have been difficult to impose upon the therapeutic phenom ena themselves. Researchers who have attacked problems in the area through experimental analogues and similar tech niques frequently have been unable to relate their findings tO ac tual therapy situations. These issues have been amply discussed by numerous writers (Bordin, 1965; Edwards and Cronbach, 1952; Ford and Urban, 1967; Frank, 1959; Glover, 1952; Goldstein, Heller, and Sechrest, 1966; Hunt, 1952; Kiesler, 1966; Sargent, 1960, 196] ). Two additional problems have limited · the practical value of previous studies in psy chotherapy, despite the fact that a number of them are of high scientific quality. One is the extreme complexity of the phenomena under study. Because of this factor, individual researchers have by necessity been forced to restrict their efforts to relatively narrow aspects of the larger problem. The other serious prnblem has been the lack of adequate com munication and cooperation among researchers. 13

Despite their caution, Bergin and Strupp suggest that the research evidence of the last ten years has shown better

Psychotherapy within the national health care system

results from psychotherapy. In 1972, they quote Meltzoff, who takes a far less conservative position on the question of the effectiveness of psychotherapy: In preparing a book on psychotherapy research I have re• viewed most of the same literature as Strupp and Bergin, as well as the bulk of the outcome and process research that has been · done on all patient types and therapeutic methods. When the evidence from controlled experiments is examined and weighed, the conclusion becomes quite clear that the effectiveness of psychotherapy with a wide variety of patient types, as ordinarily performed by journeymen therapists, has already been amply demonstrated. The research evidence to document this statement obviously cannot be presented here, but it has been steadily accumulating over the last 15 years. It now amounts to over 100 controlled outcome studies, most of which have yielded positive resulls. 14 Another overview is afforded by Bordin who summarized nearly 10 years of psychotherapy research in his recent book. 15 He reviews and discusses 685 publications in the field of psychotherapy and psychotherapy research. He, too, es chews much concern with the question of whether therapy works, in favor of discussing research methodology. How ever, in his concluding chapter he speaks briefly and defini tively on this point: As I have shown, there is respectable evidence of short or long-term effects of various aspects of the psychotherapeulic situation and of the functional relations among various com· ponents of it. True, these items of evidence are still a great distance from fostering a highly advanced level of precision in theoretical propositions and in procedural specifications, but nevertheless contradict the position of the nihilistic skeptic. 16 A team led by Imber found that outpatients with "minimal contact" brief sessions every other week improved less than patients treated with an hour per week of individual psy chotherapy or with group therapy sessions which met for an

Research on effectiveness of j}sychothempy

hour and a half each week. Many patients in all three groups experienced symptomatic relief, but at the end of six months of treatment those in the minimal contact group had im· proved the least. 17 Follow-up examinations were performed on a large number of the research subjects ten years after the original therapy and it was found once again that those in the minimal contact group were not functioning as effectively as those in either of the other two groups. 18 A similar study was done by Lorr's research team at a large VA clinic. Outpatients were randomly assigned to be seen either twice a week in psychotherapy, or once a week, or once every other week, and followed for three years after the end of therapy. No differences assignable to treatment frequency were immediately apparent, but at the end of a year, of the patients remaining in contact with the research team (a sig nificant number), those who had been seen in therapy with greater frequency showed differential improvements very similar to those observed by lmber's research team. At three years the gains were maintained and, in some respects, aug• mented. 19 In 1964, a clinical researc h team at the Psychoanalytic Clinic for Training and Research at Columbia University reported that patients with chronic ulcerative colitis who received psychotherapy in addition to the usual medical reg· imen had a more favorable somatic and psychological re sponse than did a matched control group of patients who received the usual treatment without psychotherapy. It was shown in this study that the longer the duration of treatment, the better the clinical outcome. Follow-up evaluations upon which these judgments were made took place more than five years after termination of therapy. 20, 21 One additional study will be cited which points to the difficulties of early assessment of response to treatment. In 1968, a study was begun at two clinics involving 150 moder ately depressed women between the ages of 25 and 60, from

Psydwtherapy within the national health care system

working and lower-middle-class backgrounds. All patients were treated with antidepressant medication, and after an initial treatment phase, half of the patients were assigned on a random basis to once-to-twice weekly psychotherapy, and the other half to brief monthly interviews which were not deliberately psychotherapeutic but were for assessment and prescribing. One hundred and six patients remained on medication and completed an eight-month course of treat ment. On social adjustment. scales the patients who received psychotherapy improved 44 percent as contrasted with 28 percent improvement in the low-contact group. The authors conclude: The social a<ljustrncnL of recovering depressed women, treated initially with antidepressant [medication], is enhanced by the addition of weekly supportive psychotherapy. These beneficial effects, however, take some time ro develop. They are not apparent after two to four months of treatment, but are after six to eight months, indicating that psychotherapy should not be short-term. The effects arc seen in the im proved work performance, reduced interpersonal friction, freer communication, reduced anxiety, and in overall adjust ment. :Vlaintenance [medication], either alone or with psy chotherapy, does not afford these advantagcs. 22 Finally, we would cite several preliminary studies of the effect of psychotherapy upon paLLerns of utilization of gen eral medical services. In two of these there was a clear-cul decrease in the demand for and utilization of medical serv ices. Such findings raise important and, as yet, unanswered questions about measures of cost-benefit effectiveness of psychotherapy, and they point to the need LO consider that the effect of treatment must be examined across a broad range of response systems_i;i, 24• 25• 26 It is rare that any review of psychotherapy research closes without recommendations for additional research, and this report shall not break with that tradition. It is evident that

Research on effectiveness of" psychotherafry

continued efforts in research are essential to the scientific and therapeuti� a�vanc� of medical psychology. Cc>mputers and the cent ralization of medical information on large num bers of people over a period of time open the possibility of a :vhole new era_m psychiatric research. The problem of locat mg and �oll�wmg the treatment ouLcome on a large number of psych1atnc patients is close to solution, and requires only that nece ssary resources be allocated to the research with of _ �oursc, vigorous attention Lo methods assuring confidential ity. We urge that a�tention be paid to these critical questions and that the questions not be limited to psychological vari ables. The out.come of most medical treatment is 1�1easured by responses within the 01-gan sysLern in which symptoms o:curred. Psychotherapy is unique in its ability to affect a wzck range of psychological, social, and biological functions. However, unless policy decisions are made to afford priority to these questions, they will remain unanswered.

Issues of public policy in the health care system

ISSUES OF PUBLIC POLICY RELATED TO PSYCHOTHERAPY (INCLUDING LONG-TERM INTENSIVE) IN THE HEALTH CARE SYSTEM

spread myth that long-term intensive psychotherapy and _ psychoa�alys1s _ are selectively indicated for and preferred by affluent md1v1duals to the exclusion of the economically dis advantaged. The facts are that when these modalities are made available, they are used by all socio-economic groups.21. 28

Public attitudes

Cost control

The perception of psychiatrists, particularly in their role as psychotherapists, as practicing in mysterious ways is in part based on the public's desire to avoid confronting the exist ence of unconscious attitudes in themselves, i.e., the "dark side" of their own natures. To the extent that psychiatrists enjoy this exalted status as "keepers of secrets," they must pay the inevitable price of social depreciation, as exemplified in jokes about psychiatrists. To a considerable extent, the rest of the medical profes sion expresses the same attitudes albeit in a more tangential fashion. There is a tendency for physicians to misdiagnose psychiatric conditions because of the doctor's discomfort in acknowledging the psychological factors in illness. Thus, many patients who suffer chronic depression or anxiety neurosis manifested in the form of physical complaints, are offered incomplete treatment by being denied proper psy chiatric attention. Psychiatrists are faced with the task of helping the public (including the rest of medicine) undersLand that they are neither pied pipers of permissiveness who encourage social disruption by encouraging patients to attack the societal roots of authority and promulgate sexual license without self-responsibility, nor arc they proponents of "adjustment" to an oppressive society, but rather medical specialists treat ing illnesses that have a larger than usual psychological corn ponen t to their causes or manifestations. There is a wide34

�he economics of insurance coverage for long-term inten sive psychotherapy are carefully reviewed in a recent arti cle: 29 There is no definitive evidence available for either side of this controversy [between proponents and opponents of com prehensive mental health coverage). There is, however, an increasing flow of data in support of the contention that comprehensive mental health coverage does not radically change existing utilization patterns of mental health care. 30 Sharf�tein and Magnas draw extensively from the experi ences with the Blue Cross/Blue Shield plan operating under the Federal Employees Health Benefit Program (FEHBP) because that plan is by far the largest one with accurate utilization data over a period of time. Four and a half million en�ollees in _ this plan carry the so-called "high option plan," which has, smce 1967, covered I 00 percent of inpatient. men tal health care costs as well as 80 percent of outpatient psy chotherapeutic services in excess of the first $100 in ch�rges. During· a three-year period (1971, 1972, 1973) in which r.�ere was free access in and out of the program, Sharfstem anr! Magnas conclude that the availability of un li ited intensive psychotherapy with co-payment coverage :11 did nor seem to cause any appreciable increase in the number of people utilizing this form of treatment.

Psychothernjiy within the national health care system

The majority of patients, in fact, tend to limit themselves to short-term treatments ... In each of the three years for which data are presented at least 78 percent of people in psy chotherapy limited their treatment to 25 visits a year; 90 percent restricted themselves, on a yearly basis, to one visit or less a weck.31 In discussing this same plan in his Introduction to Coverage and Utilization of Care for Mental Conditions Under Health lnsur ance 32 Sabshin states: The upward trend in utilization of benefits for mental disor ders that had characterized the high option of the Blue Cross/Blue Shield Plan for Federal Employees since its begin ning in I 960 appears to have ended. Utilization leveled off in 1973 and 1974. Thus in 1972 benefits for mental disorders constituted 7 .3 percent of benefits for all conditions; in 1973 they constituted 7.4 percent; and in 1974 they were back down to 7 .3 percent. 33 Similar findings come from another source. The Joint �nformation Service publication, Psychiatrists and Their Patients 34 is a summary of information on the private practice of psychiatry gathered from questionnaires returned by 440 randomly selected psychiatrists. In examining this data to see the effect of insurance coverage upon the duration and fre quency of treatment, one finds that the utilization of psychi atric services for insured and uninsured patients is roughly the same, indicating that the degree of utilization in terms of numbers of visits is not significantly affected by the presence of insurance coverage for this group. There is evidence that undiagnosed emotional illness, possibly because inadequately or inappropriately treated, is a major burden on the health care system and consumes a significant share of the health care dollar. It is generally acknowledged that a large proportion (estimated up to 75 percent) of patients consulting non-psychiatric specialists and family practitioners, have no demonstrable organic prob-

Issues of public policy in the health wrr. system

. . dom th at t h e greatest )ems . -35, 36' 37 It 1· s a1so convenuona1 w1s . proportion of medication prescribed by nonpsychiatric physicians is non-specific or frankly psychotropic. Over medication and misuse of medication in these situations is common. 38 Studies in this country 39• 40 and in West Germany 41 have clcr�onstrated that psychotherapy not only helps such patients solve the problems that brought them to treatment, but also reduces their tendency to seek inappropriate medical t�eatment, to receive unneeded diagnostic tests, and to expe nern�e unnecessary hospitalization. The West German study . �pec1f'.cally demonstrated the cost effectiveness of long-term intensive psychotherapy, including psychoanalysis, adminis tered by competent therapisrn. As a result of these findings, �he West German I\'ational Health Insurance System now mcl�des a significant amount of coverage for long-term in term:e psychotherapy, including psychoanalysis, effectively momtored by a peer review process. Recent finding·s 42 show that claims for outpatient mental health care outside the Federal Employees Plan also seem to be leveling off. (See p. 36 above). There are also indications that adequate outpatient care, either long-term intensive psyc�ot�er�py �r psychoanalysis may forestall psychiatric hosp1tal1zat1on. 4 This same study confirmed that usage of oth er healLh ?enefits including medical or surgical hospitali _ zation remained low following the completion of psv, . chotherapy. Plans for collaboration 44 are underway among the Ameri can Psychoanalytic Association, the National Institute for Mental Health and the National Association of Blue Shield Plans. When carried out, this collaboration will attempt to replicate in the United States the West German studv that found that long-term intensive psychotherapy or a�alysis reduced the usage of other health insurance benefits after treatment was over in comparison with a control group of

Psychothera/1y within the national health care system

its members should be chosen to represent subspecialities and all significant points of view in order that all groups may have a voice on the committee. Members should be appointed from private practice, clinic or mental health center practice, medi cal schools, etc .15 It is now clear that the quality of all psychotherapy can be reviewed, monitored, and enhanced by peer review in much the same way as the quality of other medical procedures. There is even some early evidence that cosls can be con trolled, inappropriate utilization reduced, 46 and the cost benefit ratio improved. As a result, in 1977, the Office of Civilian Health and Medical Program of the Cniformed Services (OCHAMPUS) conlracted with the American Psy chiatric Associ"ation to establish and operate a nationwide, retrospective peer review system for psychiatric CHAMPUS claims, using local peer review panels composed of psychi atrists. It should be noted that there are some problems inherent in the peer review process, and that by itself it is not suffi cient as a means of professional quality control. Peer review tends to identify and reduce incompetent or unacceptable professional behavior, but it does not necessarily improve average or above average professional behavior. In fact, the time and effort required for an effective review process may actually interfere with the functioning of superior prac titioners. Peer review that i·s designed only to control costs and to monitor the lower levels of practice, and that is not linked to educational and research programs aimed at enhancing the quality of all practice, is likely Lo lead to a deterioration of practice to a lowest common denominator. A profession is a social organization, and each professional has an obligation not only to provide quality care to his own patient, but to assure the general public that they can place their trust in any member of that profession. Peer review is an essential mechanism in responding to that obligation.

6 CONCLUSION

Psychotherapy, inclu ding-long term intensive psycho therapy, is an essential method of treatment in psychi atry. Although it has important differences from many other types of medical treatment, it shares their most essential characteristics. A growing body of scientific data supports the view of experienced physicians that, when properly prescribed and administered, it is effective and appropriate therapy. There are public and professional attitudes that interfere with its general acceptance, but data now demonstrate that its costs can be controlled, (including the costs of long-term intensive psychotherapy), its quality monitored, and that for a great many patients it is the treatment of choice. Decisions concerning its role in health delivery or health financing systems should be made on the basis of the information available about it as a medical treatment.

REFERENCES 1. David Rothman.

THE DISCOVERY OF THE ASYL!.!M: SOCIAL ORDER

(Boston: Little, Brown and Company, 1971 ). 2. M. Siegler and H. Osmond. MODELS OF MADNESS, MODELS OF MEDICINE (New York: MacMillan, 1974) 3. George Engel. The Need for a New Medical Model: A Chal lenge for Bio-Medicine, Science 196 (1977) pp 129-136. 4. Group for the Advancement of Psychiatry. PSYCHOTHERAPY AND THE DUAL RESEARCH TRADITION, GAP Report No. 73 (:'-Jew York: GAP, October 1969) p 106. AND DISORDER IN THE NEW REPUBLIC

Psychotherapy within the national health care system

5. Ibid., pp. 108-109. 6. "Psychoanalytic Peer Review," in MANUAL OF PSYCHIATRIC PERR REVIEW (Washington, D.C.: American Psychiatric Association, 1976) pp 49-61. f 7. Hans Evsenck. The Ef ects of Psychotherapy: An Evaluation, Journal �fConsultingPsychology 16, 5 (1952) pp 319-324. 8. Peter Sifneos. "Learning to Solve Emotional Problems: A Con trolled Study of Short-Term Anxiety-Provoking Psy chotherapy," in THE ROLE OF LEARNING lN PSYCHOTHERAPY, Ruth Porter, e<l (Boston: Little, Brown and Company, 1968) pp 87-99. 9. David Malan, E. Sheldon Heath, Howard Baca!, and Frederick Balfour. Psychoclynamic Changes in Untreated Neurotic Patients. II. Apparently Genuine Improvements, Archives of General Ps),chiatry 32, January (1975) pp 110-126. 10. Philip May. TREATMENT OF SCHIZOPHRENIA: A COMPARATIVE STU0Y OF FIVE TREATMENT METH0US (New York: Science House, 1968). 11. Bertram Karon and Gary Vandcnbros. Issues in Current Re search on Psychotherapy Versus Medication in Treatment of Schizophrenics, P sychotherapy: Theory, Research and Practice 12, 2 (1975) pp 143-148. 12. Ibid., p 148. 13. Allen Bergin and Hans Strupp. CHANGING FRONTIERS IN THE SCJENCE OF PsYr:H0THERAPY (Chicago: Aldine-Atherton, 1972) p 6. 14. Ibid., p 137. 15. E. Bordin. RESEARCH STRATEGIES IN PSYCII0THERAPY (New York: John Wiley & Sons, 1974). 16. Ibid., p 219. 17. Stanley Imber, Jerome Frank, Earl Nash, Anthony Stone, and Lester Gleidman. Improvement and the Amount of Therapeutic Contact: An Alternative to the Use of No Treatment Controls in Psychotherapy, Journal of Consulting Psycholof:Y 21, 4 (1957) pp 309-315. 1 8. Stanley Imber, Earl Nash, R. Hoehn-Saric, Anthony Stone, and J. D. Frank. "A Ten-Year Follow-Up Study of Treated Psychiatric Outpatie;nts," in AN EVALUATION OF THE RESULTS OF

References

PSYCHOTHERAPISTS, Stanley Lesse, ed (Springfield, Illinois: Charles C Thomas, 1968) Chapter 5, pp 70-81. I 9. Maurice Lorr, Douglas McNair, William Michaux, and Allen Raskin. Frequency of Treatment and Change in Psy chotherapy, .Journal of Abnormal and Social Psychology 64, 4 (1962) pp 281-292. 20. Aaron Karush, George Daniels, John O'Connor, and Lenore Stern. The Response to Psychotherapy in Chronic Ulcerative Colitis. l. Pretreatment Factors, Psychosomatic Medicine 30, 3 (1968) pp 225-276. 21. Aaron Karush, George Daniels, John O'Connor, and Lenore Stern. The Response to Psychotherapy in Chronic Ulcerative Colitis. II. Factors Arising from the Therapeutic Situation, Psychosomatic Medicine 31, 3 (1969) pp 201-226. 22. \.-fyrna Weissman, Gerald Klerman, Eugene Paykel, Brigitte Prusoff, and Barbara Hanson. Treatment Effects on the Social Adjustment of Depressed Patients, Archives of General Psychiatry 30, Uune 1974) p 776. 23. Raymond Fink, Sidney Goldensohn, Sam Shapiro, and Edwin Daily. Changes in Family Doer.ors' Services for Emotional Dis orders after Addition of Psychiatric Treatment to a Prepaid Group Practice Program,Medical Care 7, 3 ( 1969) pp 209-224. 24. William Follette and :'\icholas Cuinmings. Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting,Medi cal Care 5, l (1967) pp 25-�5. 25. Irving Goldberg, Goldie Krantz, and Ben Locke. Effects of a Short-Term Outpatient Psychiatric Therapy Benefit on the Utilization of Medical Services in a Prepaid Group Practice Medical Program, i'vlediwl Care 8, 5 (1970) pp 419-428. 26. Ben Locke, Goldie Krantz, and Morton Kramer. Psychiatric Need and Demand in a Prepaid Practice Program, American journal of Public Health 56, 6 (1966) pp 895-904. 27. �ettie Terestman, J. D. Miller, and J. Weber. Blue Collar Patients at. a Psychoanalytic Clinic,Ameriwn]oumal of Psychi.atry 131, 3 (March 1974) pp 261-266. 28. Frank Riessman. MENTAL HEALTH OF THE POOR (Glencoe: Free Press, 1964). 29. Steven Sharfstein and Howard Magnas. Insuring lntensive

Psychotherapy within the national heauh care system

Psychotherapy, American journal of Psychiatry 132, 12 ( 1975) pp 1252-1256. 30. Ibid., p 1253. 31. Ibid., p 1254. 32. Louis Reed. COVERAGE AND UTILIZATION OF CARE FOR MENTAL CONDITIONS

33. 34.

35.

36. 37. 38. 39. 40. 41. 42.

UNDER

HEALTH

INSURANCE-VARIOUS

STUDIES,

1973-74 (Washington, D.C.: American Psychiatric Associa tion, 1975). Ibid., p iv. "Patients' Financial Data," in PSYCHIATRISTS AND THEIR PATIENTS, Judd Marmor ed. (Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1975) Chap ter 5, p 96. Federick Mendelsohn. Long-Term Psychotherapy Coverage Under National Health Insurance, The Bulletin, Area II District Branches, American Psychiatric Association 18, 8 ( 1976) pp 1, 12. Roger Cuplan and Brian Davies. Psychiatric Illness at a Medi cal and a Surgical Outpatient Clinic, Comprehensive Psychiatry 1, 4 (1960) pp 228-235. Milton Mazer. Psychiatric Disorders in the General Practices of an Island, Medical Care 7, 5 (1969) pp 372-378. Robert Maronde, Peter Lee, Margaret McCarron, and Stanley Seibert. A Study of Prescribing Patterns, Medical Care 9, 5 (1971) pp 383-395. William Follette and Nicholas Cummings. Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting, Medical Care 5, I (1967) pp 25-35. Nicholas Cummings and William Follette. Psychiatric Services and Medi ca,l Utilization in a Prepaid Health Plan Setting: Part II, Medical Care 6, l (1968) pp 31-41. Von A. Deuhrssen and E. Jorswieck. An Empirical-Statistical Investigation into the Efficacy of Psychoanalytic Therapy, Der Nervenarzt 36, 4 (1965) pp 166-169. Federick Mendelsohn. Long-Term Psychotherapy Coverage Under National Health Insurance, The Bulletin, Area I I District

References

43. 44. 45. 46.

Branches, American Psychiatric Association 18, 8 (1976) pp 1, 12. Von A. Deuhrssen and E. Jorswieck. An Empirical-Statistical Investigation into the Efficacy of Psychoanalytic Therapy, Der Nervenarzt 36, 4 (1965) pp 166-169. Herbert Schlesinger and Emily Mumford. Personal Communi cation (1977). �ANlJAL OF PSYCHIATRIC PEER REVIEW, (Washington, D.C.: American Psychiatric Association, 1976) p 6. Paul Chodoff and Philip Santora. Psychiatric Peer Review: The Washington, D.C. Experience, 1972-75, Americanjoumal of Psychiatry 134, 2 February (1977) pp 121-125.

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