Access to Psychoanalysis and Psychotherapy in the US
Special Issue of Psychoanalytic Psychotherapy: ‘State of the Psychoanalytic Nation’
Editor: Dr Jessica Yakeley
Access to Psychoanalysis and Psychotherapy in the US
This submission summarizes the place of psychotherapy and psychoanalysis in the US health care system. It addresses trends in the field, tensions between biomedical and biopsychosocial models of mental and substance use disorders, and summarizes top-down legislative and bottom-up judicial actions that impact access to psychosocial treatments for mental and substance use disorders.
In the US psychoanalysis is a clinical discipline that has also attracted the interest of academics and other non-clinicians. Recognizing the importance of protecting the public by preserving psychoanalytic practice as a clinical discipline, and despite sometimes strong differences about the optimal structure of psychoanalytic training and practice, in 1992 a group of four US clinical psychoanalytic organizations formed the Psychoanalytic Consortium, with members representing psychiatrist and psychologist members of the American Psychoanalytic Association, psychologist members of the Division of Psychoanalysis of the American Psychological Association, psychiatrist psychoanalyst members of the American Academy of Psychodynamic Psychiatry and Psychoanalysis, and social worker psychoanalysts who are members of the American Association of Psychoanalysis in Clinical Social Work. The work of this group led to the creation of the Accreditation Council for Psychoanalytic Education, Inc. (ACPEinc) in 2001.
ACPEinc works to foster excellence in psychoanalytic education by developing clear, consistent and transparent standards for psychoanalytic education. Its accreditation process includes advance submission of application materials and site visits that explore whether these standards are met by psychoanalytic institutes and other training centers. ACPEinc standards define psychoanalysis and set minimum training requirements.
ACPEinc Standards define psychoanalysis as
[A] specific form of individual psychotherapy that aims to bring mental elements and processes that are unavailable to conscious awareness into awareness in order to expand an individual’s self-understanding, enhance adaptation in multiple spheres of functioning, alleviate symptoms of mental disorder, and facilitate character change and emotional growth. Psychoanalytic work is characterized by depth and intensity achieved in the context of frequent treatment sessions over a long term. It is expected that training institutes and programs seeking accreditation will ensure that candidates in training shall have a personal psychoanalytic experience of frequency, depth, intensity and duration adequate to provide a deep psychoanalytic experience and that their treatment of patients under supervision will have similar characteristics. (ACPE Standards, p. 1)
ACPEinc Standards require that the didactics, supervision and personal analysis that are longstanding essentials in the training of psychoanalysts meet specific requirements. For example, the Standards:
- Allow only limited access to psychoanalytic training programs for those who are not mental health professionals (ACPEinc Standards, p. 3)
- Require a minimum of 300 hours of personal analysis for candidates at a frequency of three to five times weekly (ACPEinc Standards, p.5)
- Require supervision of 2-3 cases (150 – 200 hours) for 2 years, though one case may be for at least one year, with at least one case supervised through termination (ACPEinc Standards, p. 9)
- Allow analysis of candidates to be conducted by analysts with a serious commitment to the practice of psychoanalysis, who have at least 5 years post-graduation experience, and who are certified (or the equivalent) in psychoanalysis, with the additional stipulation that the pathway to becoming such an analyst of candidates be transparent (ACPEinc Standards, p. 14)
ACPEinc accreditation is optional for psychoanalytic training sites and requires a serious commitment on the part of the entity being reviewed as well as by the reviewers representing ACPEinc. At this time only 13 training programs are listed as accredited on the ACPEinc web site out of dozens in the nation (https://www.acpeinc.org/members/). Nevertheless, ACPEinc Standards are widely recognized as minimum standards for psychoanalytic training, even if a given training entity or psychoanalytic professional organization selects more stringent standards for its own use.
Access to Health Care in the US
The United States is a nation of great wealth and great wealth disparity. It is also a nation in which access to health care and health insurance to pay for it have been viewed as voluntary choices rather than as fundamental rights of citizens. Although American founding documents refer to such inalienable rights as those to “life, liberty and the pursuit of happiness,” access to affordable health care is not among these. No one in a medical crisis is denied care in an emergency room, but there is far more to contemporary treatment of medical and mental disorders than responding to crises.
It has been said about Americans that one marker of wealth versus poverty, that is, where they live as signified by their postal zip code, reveals more about their health status than their genetic code (Graham 2016). Since “there is no health without mental health” (Kolappa et al. 2013), these access to care problems extend to treatment of mental disorders. Indeed, in 2017, the most recent year for which data are available, only about 40% of those in the US with mental disorders had seen a clinician in the previous year, and only 60% of those with serious mental illness (SMI = chronic, severe and disabling disorders like schizophrenia and major mood disorders) (NIMH 2019). Too many of those with mental or substance use disorders become homeless or incarcerated, with 15-20% of US prison inmates struggling with serious mental illness (Shenson et al. 1990).
About half of Americans have health insurance through employment. Another large proportion are covered by state or federal public options (Medicaid, Medicare and the Veterans Administration system of health care) because they are indigent, over 65, disabled, or veterans of military service, but tens of millions are uninsured.
Such large-scale societal problems are beyond the scope of psychoanalysis and psychotherapy, but these forms of treatment are influenced by the overall social context -- and might have contributions to make toward the resolution of these social problems.
The Expansion of Managed Care
In the 1990s, partly in response to an extended period of annual double-digit inflation in health care costs, President Bill Clinton undertook an effort to introduce national health insurance. When this effort failed there was a dramatic expansion of so-called “managed care” by insurance companies to control costs. Managed care involves review of the utilization of treatment by third party payers, including making decisions about what kind and duration of treatment to reimburse. It is worth noting that managed care operates with the same moral imperative as the environmental movement; it is an effort to manage limited resources in the provision of medical and surgical treatment and mental and substance use disorder treatment. In the treatment of mental and substance use disorders, though, utilization review criteria introduced by managed care generally limited treatment of mental and substance use disorders to the goal of stabilizing crises (Plakun 2018a). Hence, mental health clinicians, including psychotherapists and psychoanalysts, and their patients, frequently experience denial of managed care authorization for payment of recommended and medically necessary treatment intended to pursue goals beyond crisis management. These goals include treatment of underlying and comorbid conditions, a set of goals usually referred to as pursuit of “recovery.” Recovery is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA 2014) as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
In addition to limiting access to treatment for mental and substance use disorders to crisis stabilization, insurance entities imposed other barriers to access treatment of mental and substance use disorders. Unlike the situation in medical and surgical treatment, lifetime or annual limits were applied to access to treatment of mental disorders. This might take the form of an annual or lifetime dollar limit for expenditures, or a defined and limited number of inpatient days or therapy sessions covered annually. Prior authorization and concurrent review hurdles were imposed to begin or continue treatment of mental and substance use disorders, with significant amounts of uncompensated clinician time required to advocate for treatment. Further, even those outpatient sessions authorized and reimbursed through managed care utilization review were compensated less than comparable services provided by other physicians. For example, Milliman, a healthcare statistics research company, reports that the same procedure to treat a patient with a mental disorder carried out by a primary care physician was compensated on average at a 20% higher rate than if it were carried out by a psychiatrist (Melek et al. 2017).
According to America’s Mental Health 2018 study, 42 percent of the US population considered cost and poor insurance coverage top barriers for accessing mental health care, and 25 percent reported having to choose between getting mental health treatment and paying for daily necessities (Cohen Veterans Network and National Council for Behavioral Health, 2018).
Negotiating insurance support for treatment of mental and substance use disorders was harder to achieve than for treatment of medical and surgical disorders, and the goal of treatment of mental and substance use disorders was frequently limited by insurance reviewers to achievement of crisis stabilization followed by prompt discharge and/or the end of treatment (Plakun 2018a).
Biomedical or Biopsychosocial?
Concurrent with the expansion of managed care, the mid-twentieth century hegemony of psychoanalysis in American psychiatry was declining, with a shift toward a biomedical model emphasizing brain science and use of medications, and away from the earlier biopsychosocial model. Academic departments of psychiatry were no longer chaired by psychoanalysts, while most psychoanalysts were driven from academic teaching positions. Training of psychiatry residents in psychotherapy diminished so dramatically that in the late 1990s the Accreditation Council for Graduate Medical Education Residency Review Committee in Psychiatry introduced requirements mandating that psychiatrists receive training in psychotherapy, while the American Psychiatric Association (APA) developed a Council (later transitioned to a Committee) on Psychotherapy by Psychiatrists to ensure that this dwindling skill was preserved. Required residency training for psychiatrists currently includes training in psychodynamic, cognitive behavioral and supportive psychotherapies—though residency programs vary in their ability to teach these therapies to residents to a level of competence.
In 2009, in response to a worldwide recession that strained its finances, the APA ended the Committee on Psychotherapy by Psychiatrists along with 90 other committees and councils. However, within a few years APA members successfully petitioned the APA to form an APA Psychotherapy Caucus – currently a 500 member “big tent” organization that welcomes psychiatrist psychotherapists of all theoretical orientations in order to preserve psychotherapy and psychosocial treatment as part of the training, skills and identity of psychiatrists. The largest subgroup of members of the Psychotherapy Caucus identifies as psychodynamic or psychoanalytic in orientation. Caucus members of all psychotherapy orientations work in a range of settings, from outpatient private practice, to acute inpatient psychiatry, to intermediate levels of care like residential treatment centers or intensive outpatient programs, to consultation liaison psychiatry in general hospitals, to criminal justice and other settings. Psychotherapeutic training, especially psychodynamic or psychoanalytic training that includes attention to understanding group process, is a distinct advantage when working with difficult patients in any setting and in complex treatment systems.
There was widespread belief in the late 1990s that, once the human genome was decoded, the diagnosis and treatment of all disorders, including mental and substance use disorders, would be transformed, as the genes underlying these disorders were discovered and treatments designed to target them (Collins 1999). However, with few exceptions, this has not proven true in general medicine or in mental and substance use disorders. Major mental disorders like depression and schizophrenia are found to be associated with dozens to hundreds of bits of relevant genetic material (single nucleotide polymorphisms or SNPs) that are often not disorder specific. Meanwhile, early adverse experiences emerged as major contributors to the presence and persistence of one or more mental and substance use disorders (Plakun 2018b). The initial belief that Genes = Disease shifted to recognition that Gene-by-Environment Interaction = Disease . . . and health (Plakun 2018b). Since gene-by-environment is just another way of saying biopsychosocial, emerging evidence appears to support the biopsychosocial model over the biomedical model.
Similar hope that extensive study of the brain would lead to improved diagnosis and treatment of mental and substance use disorders also failed to have a significant impact on treatment or outcomes. It turns out that the same or similar brain regions form a connectome that appears to be involved in multiple disorders.
Psychotherapy and Psychoanalysis
Of course, other disciplines beyond psychiatry, like psychology and social work, continued to focus on psychotherapy even as psychiatry became more biomedical and psychopharmacologic. An emphasis on symptom suppression, crisis stabilization and evidence-based, diagnosis-specific forms of therapy that could be tested in randomized trials contributed to a growing preference for cognitive behavioral therapies over psychodynamic therapy or psychoanalysis. CBT’s robust evidence base placed psychoanalytic and psychodynamic treatments at a disadvantage. However, even with studies showing the “non-inferiority” or “equivalence” of psychodynamic therapies to CBT for multiple disorders, psychodynamic therapies have tended to be overlooked in such areas as inclusion among practice guideline recommendations and approval of research grant funding (Plakun 2018b). Abbass and colleagues (2017) have summarized evidence of systemic bias against psychodynamic therapy in North America and proposed solutions to this thorny problem.
The US healthcare system resembles a patchwork quilt, with a mix of publicly and privately insured and individually funded self-pay treatment of mental and substance use disorders, including psychotherapy. Although individual parts of the patchwork collect data relevant to their needs, including in such areas as waiting times and outcomes, capturing reliable national usage statistics is a challenge. In 2007, the last year with reliable data, Olfson and Marcus (2010) report that 3.18% of the US population of then around 301 million people reported more than one psychotherapy session that year. Hence, about 10 million people in the US are in psychotherapy in any given year. How many are in psychoanalytic treatment? A 2015 report from the American Psychoanalytic Association noted 3109 members with an average of 2.75 patients per therapist – or 8550 total individuals in treatment with psychoanalysts in the US (Leonard 2015).
If we include analysts who are not members of the American Psychoanalytic Association, we might round up the total number of those in therapy with a psychoanalyst to about 10,000, or roughly 0.1% of those in therapy. Even if we add additional analysts who belong to the smaller Academy of Psychodynamic Psychiatry and Psychoanalysis, the American Association of Psychoanalysis in Clinical Social Work and the Division of Psychoanalysis of the American Psychological Association, it is still hard to imagine that even as many as 50,000 Americans are in psychoanalysis proper in the US—less than half of 1% of those in therapy. Of course, many therapists identify as psychodynamic even if not trained as psychoanalysts or eligible for membership in the American Psychoanalytic Association. However, given the dominance of cognitive behavioral and supportive therapy in the US, it appears likely that psychoanalytic treatment accounts for a relatively small portion of the psychotherapy offered in the US.
The cumulative effect of these forces on psychodynamic therapy and psychoanalysis was to shift much practice of longer-term individual therapy away from coverage by health insurance and into a self-pay marketplace. Those who seek therapy or analysis are often forced to pay out of pocket because insurance entities limit treatment to crisis stabilization, because arbitrary limits in numbers of sessions are imposed, because financial compensation for sessions is low, because of the nuisance of performing frequent utilization reviews, and because of bias suggesting that psychoanalysis and psychodynamic therapies are not adequately evidence based.
Adaptation of the practice of psychoanalysis and psychotherapy to a self-pay market niche allows such treatment to continue to be available to a small segment of those in need. However, psychoanalysis refers to more than a form of individual treatment. Thought of more broadly, psychoanalysis offers a way of thinking about human development throughout the life cycle, and about the contributions that come from applying learning about individual and group unconscious processes to the understanding of individuals, groups, families, and the dynamics of complex systems, like treatment teams, hospitals or even nations (Plakun 2012). For example, it is increasingly clear that even with use of psychoactive medications, the meaning of a medication matters as much as its biochemistry (Mintz and Belnap 2011).
Especially when the goal of treatment is recovery rather than mere crisis stabilization, it is this part of psychoanalysis that has the most to offer to the large number of people in therapy and other kinds of treatment for mental and substance use disorders in the US and elsewhere. A secure self-pay market niche for psychoanalysis as an intensive dyadic treatment may offer some comfort, but the loss of a psychoanalytic or psychodynamic perspective to integrate the overall treatment approach to people struggling with complex disorders would be a major loss to the field and to millions of patients pursuing recovery.
Promising Social Policy Changes
Although psychoanalysis, psychodynamic therapy and psychodynamic psychiatry continue to have significant theoretical influence in the field, they are economically marginalized by the insurance industry. There are some signs that this may be changing.
Since the expansion of managed care in the US in the 1990s, top-down legislation and bottom-up litigation have begun to reshape the landscape of care for mental and substance use disorders. Among the top-down legislative influences was the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA or mental health parity law), which required that, if an insurance entity provided mental and substance use disorder benefits, obstacles to access these benefits could not be substantially more stringent than those to access medical and surgical care. This applied to obstacles that were quantitative, like day, dollar or number of session limits imposed on access to mental and substance use disorders but not on medical or surgical disorders, and to qualitative limits, like higher utilization review hurdles to access mental or substance use disorders compared to medical and surgical disorders.
In 2011 the Affordable Care Act (ACA) increased access to health insurance through expansion of public insurance options like Medicaid and through a legal mandate requiring the purchase of health insurance by individuals -- with need-based financial support for these mandated purchases. In addition to providing insurance access to millions of previously uninsured Americans, the ACA also reinforced the terms of the mental health parity law, required that coverage for mental and substance use disorders be included as part of the essential benefit package of ACA insurance plans, and mandated that previously secret criteria for access to care be disclosed to those denied treatment.
However, despite these advances, 12 years after passage of the mental health parity law, implementation of it is still incomplete. In 2020, the bipartisan Mental Health Parity Compliance Act, which would require insurance companies to make public their degree of compliance with the terms of the mental health parity law, is moving through Congress.
Bottom-up judicial actions have also had an impact. These legal actions are based on recognition that many insurance entities have been substituting the goal of crisis stabilization for the actual generally accepted goal of treatment for mental and substance use disorders, which is pursuit of “recovery,” as noted above. Class action lawsuits, representing large numbers of patients who form a “class,” have been filed against insurance companies, alleging that they breach their fiduciary duty when they substitute the treatment goal of crisis stabilization for the generally accepted goal of pursuit of recovery.
In Wit v. United Behavioral Health/Optum (Wit v. UBH), the class of plaintiffs alleged a systematic breach of fiduciary duty in the use of flawed access to care criteria for outpatient, intensive outpatient and residential treatment by UBH, the nation’s largest behavioral health insurer (Appelbaum and Parks 2019). In his landmark verdict for the plaintiffs in the liability phase of the trial, Chief Magistrate Judge Joseph Spero of a Federal District Court in California faulted UBH for focusing treatment too narrowly on crisis stabilization rather than on addressing underlying issues and co-occurring disorders, and for putting profits above fiduciary duty to patients.
In their summary of Judge Spero’s 106-page verdict in the liability phase of the trial, Appelbaum and Parks cite eight central principles of generally accepted standards of care (2019, Box 1):
- Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms.
- Effective treatment requires treatment of co-occurring mental health and substance use disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders when determining the appropriate level of care.
- Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective.
- When there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care.
- Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration.
- The appropriate duration of treatment for mental health and substance use disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment.
- The unique needs of children and adolescents must be taken into account when making decisions regarding the level of care involving their treatment for mental health or substance use disorders.
- The determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.
Recognition in federal court that generally accepted standards for treatment of mental and substance use disorders go beyond mere crisis stabilization is relevant for all levels of care, but especially for longer-term psychotherapies and psychoanalysis. Taken together, these top-down pieces of legislation and bottom-up litigation victories should influence managed care entities to support the pursuit of recovery and increase access to psychotherapy and, potentially, psychoanalysis.
The situation is far from resolved, though. President Donald Trump does not support the ACA and has made repeated attempts to weaken it. During his administration the nation saw the first increase in uninsured individuals in the US since the ACA became law. Although President Trump spoke of his intention to “repeal and replace” the ACA with better and less expensive health insurance for all, no plan has been offered beyond eroding the terms of the ACA to lower the cost of health insurance—for example removing coverage for mental and substance use disorders as part of the essential benefit package.
President Trump will stand for re-election in 2020, opposed by a yet to be determined candidate from the Democratic Party. There are signs the US electorate may be ready for government action to bring access to health care to all. Among potential Democratic Party candidates two ideas have been discussed prominently.
Some candidates propose expanding and building on the ACA, with a wide range of private and public insurance entities continuing to offer insurance plans. Given that the average American stays with a job offering a health insurance plan or with a particular insurance plan for just a few years, continuing to approach national health insurance by offering a choice among multiple insurance plans creates an incentive for insurance companies to avoid concern about lifetime health outcomes. Instead, the incentive is to “kick the can down the road,” limit treatment to the goal of crisis stabilization, and increase profits by expending less on treatment (known as “loss” in the world of health insurance), with the hope that, by the time of any recurrence, the insured will be covered by another insurer.
Another approach discussed by some potential candidates is expansion of Medicare, the national health plan for those over 65 or disabled. This “Medicare for All” approach would end private health insurance as it is known in the US. In addition to concerns about the expense of such an approach and the market power of insurance companies to resist such change, this has a specific disadvantage for those hoping to access benefits for mental and substance use disorders. That is, the legal structure creating Medicare predates the mental health parity law, which does not apply to Medicare. Expansion of Medicare to make it available to all would undo the benefits of the mental health parity law unless the revised Medicare for All plan were amended to include mental health parity.
The Future of Psychoanalysis and Psychotherapy in the US
Psychoanalysis is probably secure in its role treating a small number of Americans with the means to pursue it. An important question is whether organized psychoanalysis is satisfied with this narrow treatment niche or whether it hopes to influence the treatment of the other 99.5% of those receiving therapy in the US. Such a goal would require determination and systematic effort.
In the US and elsewhere we have work to do to push back against bias that limits insurance support for such treatments, that limits access to research funding, and that limits inclusion of psychodynamic treatments in practice guidelines. It is promising that training in psychoanalysis and psychodynamic therapy continue, that the efficacy of such treatments is now supported by over 200 studies, and that psychoanalysis and psychodynamic therapy have been found to be “non-inferior” or “equivalent” to other therapies like CBT (Plakun 2018b). Similarly, there are reasons to believe that psychodynamic therapy and, especially, a biopsychosocial approach informed by a psychodynamic perspective, may be particularly helpful for the growing segment of patients who prove to be “treatment resistant” to our evidence-based treatments (Plakun 2011). Making a case in the field, in social policy arenas and in the lay media for the value psychoanalysis and psychodynamic therapy offer as individual treatments, but also for the value psychodynamically informed treatments bring to large scale problems in the treatment of mental and substance use disorders, is a challenge for our time.
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This is an original manuscript / preprint of an article published by Taylor & Francis in Psychoanalytic Psychotherapy on July 17, 2020, available online: http://www.tandfonline.com/ 10.1080/02668734.2020.1750052.