|The Consortium Agreement and the Future of Psychoanalysis
Eric R. Marcus, M.D.
Throughout the professions in America today, economic and political forces are heading in the direction of de-professionalization, decreasing economic incentive, increasing patient volume, and shift to less costly treatment modalities. What began as physicians spending less and less time with more and more patients, and with physicians crossing specialty boundary lines in order to prevent depletion of their income, has accelerated to include the credentialling of less well trained healthcare providers.
In all specialties, the fight is on to preserve certification boundaries in order to preserve levels of craftsmanship and quality of care. Several of the more recent examples are the fight by psychiatrists against the move by psychologists to acquire prescribing authority. A similar fight is going on by anesthesia physicians against the move by nurse anesthetists to function independently. Still another fight is between primary care physicians against primary care nurses who are opening independent practices.
However, nowhere except in psychoanalysis are physician organizations attempting to give away their certification to less highly trained groups. All other physician groups are fighting.
Why is it that now psychoanalysis is ready to give away its long fought for and heretofore zealously guarded certification? The arguments fall usually into three general groups. All of them are mistaken. The following discussion will highlight these arguments and show how they are misguided.
The first general argument in favor is often, interestingly enough, not an argument about the virtue of these efforts, but the necessity. "It's going to happen anyway, so it's better for us if we join it now, and thereby, help shape it." In fact, it won't happen unless we actively facilitate it.
"It's going to happen anyway," in the initial discussion with the proponents of the consortium, usually refers to the politics of the issue. Proponents claim that the social workers will go around us to certifying organizations in the federal government and gain national certification power and monopoly over the term psychoanalyst. It will then be their definition, their standards, their certification, and physician analysts will be left out in the cold.
Aside from social worker intentions, there is little factual basis to support this claim. There is much factual basis to refute the claim. The facts are that when the delegation from the American Psychoanalytic Association met with potential federal certifying agencies like COPRA (Committee on Recognition of Post-secondary Accreditation) and the Department of Education, the delegates were told that if the federal government certified anyone it would be the American Psychoanalytic Association because alone among the psychoanalytic groups, we had actual experience setting standards for institutes, inspecting them, certifying them and likewise setting standards for, inspecting and certifying our individual members. The social workers were way behind in developing any standards at all. Ironically, they now know what those standards are because the American Psychoanalytic Association wrote them up and handed them to the social work organizations! This very mistaken action is now used to justify joining with the social workers!
If the politics really wasn't the reason that the American Psychoanalytic Association leadership joined with the social workers, what did they really mean when they said "It's going to happen anyway"? As far as I can tell, they meant two things. One is that they felt it was going to happen anyway economically. The other is that they felt it should happen as a social good.
That it's going to happen anyway economically is only partly true. There is a growing disparity within the middle-class between the upper third who has joined with the wealthy, and the lower two thirds who are being pushed down. It has meant that all goods and services are relatively more costly and relatively more unaffordable. It has meant that some can only afford the fees of non-physician analysts. They must therefore accept the wider variation in quality.
Our leadership has decided to help society by accepting this and by inculcating and promulgating our standards for them and certifying them under the same umbrella and with reportedly the same standards with which we certify ourselves. Our leadership wants to raise social work analytic standards as a social good. The goal is high quality low cost psychoanalysis for all in need of it. This benevolent gesture is doomed to failure on two grounds. The first is the educational and the second is economic.
The educational issue is that you can never guarantee the uniform quality of the allied professions no matter what your standards nor no matter how rigorously you try to adhere to them. This is partly because their education is very different. A master's level social work degree is two years past college. An M.D.'s training involves four years of medical school plus four years of psychiatric residency for a total of eight years. Of greater concern is the destruction of clinical training that has occurred in the allied professions, even more devastatingly than it has occurred within the medical profession. Social workers are being used for rapid placement and less and less clinical assessment and treatment within hospital and clinical settings. It has gotten so bad,that my social work friends who teach in the social work institutes complain that even the "caseness" of patient care and of clinical thinking has been destroyed. Their students no longer can get clinical proficiency as prerequisite to analytic training. (Please realize that I am not arguing against gifted individual social workers being given waivers to join the American).
But even if this were not the case to the extent that it is, the economic argument would be sufficient for great caution on our part. The economic issue that the proponents of the Consortium overlooked is the principles of distribution that are well known to all health policy analysts in public health. The principle is that you can choose any two out of three among the variables quality, cost, and distributive access. You can never have all three. In other words, if you lower the price, and you increase the access, you will also lower quality. If you keep the quality high, and you lower the cost, you will limit the access. If you keep the quality high, and you increase the access, you will increase the cost. Policy experts who propose widened access for all of healthcare are willing to see the quality drop for the sake of trying to improve the quality of care of the disenfranchised and the very poor. When quality falls, all professional organizations, particularly physician organizations, respond to this public health threat (and falling quality is a public health threat) and economic dilemma by reinforcing their professional standards and boundaries. This is not in an effort to fight better medical care for more numbers of people, but an effort to protect the quality and craft levels of the profession without which all people with all incomes or lack of incomes will suffer.
The distributive justice argument, naive in its economic and public health aspects, also naively tinkers with a psychoanalytic delivery structure that has held up well in the eyes of those of us who have committed parts of our careers to treating the poor. That structure involves a private practice structure and a supervised clinic structure. In New York City, where some of the highest fees in the world for private practice analysis are maintained, there is also a most outstanding clinic structure, where patients can get psychoanalytic treatment with graduate M.D.s who have finished their psychiatric residencies and are in analytic training, supervised by the most experienced members of our profession. Are we flooded with such patients? On the contrary. We're looking for more. There is therefore no economic or intellectual justification, and no public policy justification, for altering and diluting our standards. The result of such efforts will be severely detrimental to the stated quality goals of the proponents of the Consortium.
Space does not permit an elaboration of this brief. However, in summary it could be said that in answer to the assertion it's going to happen anyway, no, actually it's probably not going to happen anyway. In response to the assertion that it's better for us and our craft if we join it, well, it's better if we don't. In response to the assertion that it's better for patients if we join it, probably it's disastrous for patients if we join it.
Remember that once the fences are down, the foxes mingle among the chickens. The only reason we haven't been destroyed by managed care and single party payers is that so far they've refused to pay for us. The moment they do is the moment of our destruction. But fortunately, there is no collective medical plan of any arrangement anywhere in the world that, for more than 10 or 15 years, has paid for psychotherapeutic treatment let alone psychoanalytic treatment, without either going broke or stopping the payment. This includes the communist and noncommunist countries, it includes the social welfare countries of Western Europe, it includes not only the onerous managed care plans of today but also the benevolent point-of-service insurance plans of yesterday. At the end of the last century, midwives delivered babies in America. By the turn of the last century, physician obstetricians did. How did this happen? The physicians convinced the American people that they had the training, they had the education, they had the standards, and they had the certification. There is no physician group that has ever voluntarily given these factors up. Will we be the first? Before we do so, we had better think hard and long about why the others have not, what we hope to gain by doing so, and whether or not we have really had a chance to think about, discuss and vote our individual consciences on this matter.
In your thinking about this please think about the above and also the following: the educational standards proposed by the Consortium do not come close to meeting minimal acceptable standards for training in the American. Acceptance of the Consortium's educational standards would therefore increase the confusion of the public and decrease the likelihood of the stated goal of the proponents which is to have a freestanding quality psychoanalytic profession composed of many different professional groups.
Our membership should realize that far from a fait accompli, this proposal is gathering growing dissent. Representatives from other societies of the American have specifically voted against continuing negotiations for the Consortium. New England, and New Orleans have voted against. NYU has abstained. We need to think about these issues, discuss them among ourselves and make our opinions known vigorously and vociferously to our leadership because they are deciding crucial issues of our future without a vote of the membership. All the goals of the Consortium can be achieved by close political and public relations liaison with the other association organizations. This would not mean the necessity of sharing credentialization. Each group can credential its own.