Psychoanalytic Therapy as Health Care: Effectiveness and Economics in the 21st Century

Psychoanalysts collide with managed care in stressing the following values: 1) emphasizing privacy rather than external review, 2) trusting therapists rather than mistrusting them, 3) valuing the most highly trained therapist rather than the least costly therapist, 4) striving in treatment to obtain the maximum desirable growth rather than minimally acceptable function, 5) stressing the imperative of the patient’s welfare rather than the imperative of the corporate market, and 6) applying costs only for the treatment rather than for administration, marketing, and profits as well.

This book’s two dozen authors, mostly members of the American Psychological Association’s Division of Psychoanalysis, provide an elegant championing of the psychoanalytic view of this collision. The authors agree with their psychiatric colleagues (1, 2) that coverage of psychoanalysis is cost-effective in that it achieves greater resilience for patients to future stresses. Within this book’s clarion call, however, there are some tensions.

One of the authors, Marvin Hyman, argues against psychoanalysis being part of health care, believing that psychoanalysis will never remain pure within medicine because psychoanalysis’ sole purpose of analyzing remains incompatible with assuming responsibility for a patient’s life. Although the other authors do not agree, they do not meet Hyman’s argument head on.

A second tension is the degree to which psychoanalysis should be regarded as a science. Alan Stone’s position (3), that psychoanalysis has survived as an art but has failed as a science, troubles psychologists. Psychologists want at least one foot at all times solidly on the base of science. Further, the authors do not recognize physicians’ understanding that the broad art of establishing the physician-patient relationship has considerable therapeutic power. These authors write as though only a psychoanalyst works the therapeutic relationship.

Trying to keep one foot at all times solidly on the base of science leads the editors to conclude that psychoanalysts must demonstrate that “we are able to help patients reduce significantly their vulnerability to future psychopathology and impairment in adaptive functioning and improve the quality of their lives” (p. 277). That comes close to playing by managed care’s rules. None of the authors seems interested in seeing psychoanalysis become scientific through the discoveries of basic science (4), probably fearing the uncertainties of that epistemological approach.

In reading this book, it becomes clear why, of all the mental health professionals, psychoanalysts have provided the leadership over the past 15 years in the challenges to managed care.