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JOURNAL OF PSYCHOThERAPY PRACTICE AND RESEARCH

Developing Practice Guidelines forPsychoanalysis

SHEILA HAFTER GRAY, M.D

Consensus-based pra dice guidelines cod�ft

dinical intelligence and the rich oral tradi-tion in medicine. Because they reflect actual

practice, they are readily accepted by dini-

cians as a basis for external review. This arti-

cle illustrates the development of guidelinesfor a psychoanalytic approach to the large

pool ofpatients who present with a depres-

sion. It suggests an integrated biopsychosocial

approach to these individuals that is useful in

current practice, and it offers propositions

that may be tested in future research under-takings. Eventually, practice guidelines such

as these may form the basis of economical sys-

tems of health care that avoid arbitrary, dini-cally untenable limitations on services.

(The Journal of Psychotherapy Practice

and Research 1996; 5:213-227)

In this article, I will outline how psychiatrists

may formulate practice parameters in away

that benefits our professional development

and the care we offer our patients. Practiceparameters are strategies for patient manage-

ment that are developed to assist physicians in

clinical decision making. They describe the

range of acceptable approaches to diagnosing,

managing, or preventing specific diseases orconditions. Because they reflect the diversityof clinical medicine, practice parameters vary

considerably in content, format, and degree ofspecificity. Some are standards; some are

guidelines. They may be based on statisticaloutcome studies or on clinical consensus.

Outcome-based parameters derive theirstrength but also their weakness from theirresearch foundation. Although there have

been several good outcome studies on psycho-analysis,’ the body of knowledge is inadequateto form the basis of a generally applicablepractice parameter. At present, guidelines forpsychoanalysis derived from outcome studies

alone would be incomplete and difficult to

implement.

Consensus-based practice guidelines fo-cus on the experience of clinicians, and they

acknowledge the complexity of the individualpatient. They codify and integrate existing

clinical intelligence and the rich oral tradition

Received June 8, 1993; revised February 22, 1996; ac-

cepted February 28, 1996. From the Department of Psy-chiatry, University of Maryland School of Medicine,Baltimore, Maryland, and Department of Psychiatry,

Walter Reed Army Medical Center, Washington, DC.Address correspondence to Dr. Gray, P.O. Box 40612,Palisades Station, Washington, DC 20016-0612.

Copyright © 1996 American Psychiatric Press, Inc.

214 GUIDELINES FOR PsYcHo�i�YsIs

VOLUMES #{149}NUMBER 3 #{149}SUMMER 1996

in medicine. This makes them better suited

than outcome-based parameters for the task ofhelping the psychiatrist integrate the biopsy-chosocial aspects of a case. Their delineationof actual contemporary practice also serves

the research goal of defining patterns of prac-

tice that are appropriate for scientific investi-

gation.

TOWARD

GUIDELINES

DEVELOPING

Allocating Therapeutic Resources

One ordinarily bases the allocation of

therapeutic resources on medical necessity.

Peer review is the traditional procedure to

monitor this process.2 When we delineate theknowledge base we implicitly use in this peerreview process, we have taken a first step in

the development of a practice guideline basedon clinical consensus.

The nature of psychotherapy and psycho-

analysis requires that this effort to codify be

principled, voluntary, and based on broadconsensus among practitioners. The guide-

lines must respect and protect the special

doctor-patient relationship that makes psycho-

therapy possible. They must contain a large

measure of appreciation of the individual dif-ferences among patients and among psychia-

trists. In the absence of definitive knowledgethat mandates an unequivocal treatment plan,they must accommodate a range of theoreticaland practical approaches to a disorder, and

they must state criteria for a successful out-

come. They must do all these things not in an

ideal space populated with paragon patients,

but in a context of clinical reality.

I selected medical psychoanalysis (CFT

90845) as the model psychotherapy to study

from this perspective. My earlier work3 re-vealed that principles and procedures that sup-port this modality are generally useful forother individual medical psychotherapies(CPT 90844). I selected the specffic clinical

situation ofa patient who presents with depres-

sion because the American Psychiatric Asso-

ciation was working on the Practice Guidelines

far Major Depressive Disorder in Adults.4

Issues Relevant to Constructing Guidelines

ImportantSubjeaMauerk Unknown: Classicalpsychoanalysis and certain schools of dynamic

psychiatry rest on a fundamental assumption

that people are motivated by ideas and feel-ings of which they are unaware and of whichthey cannot spontaneously become aware.5These motive forces are responsible for the

formation of symptoms, dreams, and person-ality.6 Behavior-oriented psychoanalytic theo-

rists assert similarly that mental disorders

contain an important component of dis-

avowed or unacknowledged wishes.7 We

avoid the problem of unknown mental con-tents by focusing on observable aspects of the

patients. These are presented in terms of theformal mental status examination, a full DSM-

N diagnosis, and a description of the patients’

actions, including their verbal activity in the

sessions. This approach lacks metapsychologi-

cal mystery, but it is accurate and replicable.Kantor� has delineated the diverse findings ofthe mental status examination in Axis I andAxis II disorders in a way that integrates thebiopsychosocial aspects of each case.

Outcomes Are Unique: Psychoanalytically in-

formed dynamic psychotherapy focuses onthe patient’s inner life. Its aim is described bysome as the development of insight or self-un-

derstanding,’#{176} the revision of one’s history,”2or the construction of a coherent and comfort-able sense of self.’3 It may involve the discov-ery of memories of which patient andpsychiatrist are, by definition, initially igno-

rant5 Awareness is the anticipated conse-quence of a process that begins with theestablishment of a special doctor-patient rela-tionship, the therapeutic alliance,’4 and goeson through the elucidation of here-and-nowtransferences to the point at which one re-members or reexperiences the associated pastdifficulties and reevaluates them in light ofcontemporary circumstances. One may then

215

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

develop a more coherent sense of self, or

restructure one’s personality, or rewrite one’shistory, or resume emotional growth.’5 Be-

cause the description of these outcomes isunique to each case, to operationalize thesevariables for an outcome study may at this

time be beyond our technical grasp.’6

The Review Process Always Changes The Case:

Each method of review, including a clinician’sself-review, has its particular risks and benefits.Each must be scrutinized from the viewpointof its impact on the clinical psychotherapeuticsituation and its specific meaning or meaningsto the patient. Lipton,’7 for example, docu-

ments the adverse impact on cases of ordinary

scientific communication. Because of this phe-nomenon, psychoanalytic cases are extraordi-narily difficult to review.

Writing Notes Degrades Technical Qjtality: A sub-committee of the Committee on Peer Review ofthe American Psychoanalytic Association re-cently studied this problem. It concurred withAdams-Silvan’8 that the process of creating

daily notes itself violates the core psychoana-

lytic technique of listening with even-hovering

attention.’9 Notes are therefore not likely to be

available as a database for review of psycho-

analysis.

Extending Clinical Consensus

Following dynamic treatments over the

long term, then, is complicated by the unique-

ness of each procedure, by the requirement topreserve the therapeutic alliance, and by the

possibility that the review process will sabo-

tage the therapeutic process. In this environ-

ment, practice guidelines might be viewed as

another ruinous encroachment on the delicate

doctor-patient relationship.

I propose that we may mitigate this out-

come if we construct guidelines by a process

of clinical consensus that reflects the special

technical problems of psychoanalysis. In 1975,

agroup of psychoanalysts of the Baltimore and

Washington Psychoanalytic Societies who

were members of the Washington Psychiatric

Society did just that The joint Committee ofthe Washington and Baltimore-District of

Columbia Psychoanalytic Societies for Estab-lishing Peer Review Standards for Psycho-analysis developed guidelines for peer reviewof psychoanalysis and modified psychoana-lytic treatment of adults, adolescents, and chil-dren. These guidelines served the DistrictBranch well in its cooperative work with theUtilization and Peer Review Committee of theMedical Society of the District of Columbiaand with the American Psychiatric Associa-

tion’s Peer Review Projects. Colleagues

tended to heed comments based on these

guidelines because they owned them. This

report describes an effort to continue this ap-

proach at the national level.

METHODS

This project stems from an effort to gather factsand opinions on which to base the AmericanPsychoanalytic Association’s response to the

American Psychiatric Association’s Draft

Practice Guidelines for Major Depressive Dis-order in Adults. I solicited comments frommedical psychoanalysts from components of

the American Psychoanalytic Association,asking them to focus on how they approachedpatients who presented with depression.

About thirty individuals who had been se-lected to speak for their local groups offeredwritten contributions. I encouraged the col-

leagues to tell me what they do and, if theycould, why they do it. We also held three smallhalf-day conferences at the scientific meetingsof the Association. I used a traditional psycho-analytic methodology, listening to people, un-derstanding the basis of their concerns and theiractivities, and reflecting this understanding backto them in their own language20-the techniqueof clarification.2’ I tried to abstractfrom ourlaz�ge

psychoanalytic case literature principles thatseem to have guided dinicians toward certain

interventions and away from others. I set out theprocess in a logic-driven procedure diagram,�which I asked colleagues on the Committee on

216 GUIDELINES FOR PSYCHOj�T��YSIS

VOLUME S #{149}NUMBER 3 #{149}SUMMER 1996

Peer Review to test The aim was to have a set

of explicit statements that reflected actual

clinical practice.

RESULTS

The American Psychoanalytic Association’s

early guidelines for prescribing psychoanaly-

sis� are expressed diagrammatically in Figure1. The procedure diagram I developed (Figure

2) incorporates these early guidelines. It de-

lineates my best assessment of how good-

enough psychoanalysts, to use Winnicott’sconcept, approach a person who complains of

depression. Both diagrams await field trials,based on which there may be further revisions

before official action by the Association.

Psychoanalytic Treatment of

Patients Who Present With Depression

We begin with an undifferentiated groupof patients, and in successive steps we isolate

those who require and can benefit from psy-choanalysis. In this system, psychoanalysis is

the treatment of last resort

In itial Assessment: We begin with a rapid as-sessment designed to answer the question,

“Does this individual suffer from a mentaldisorder?” This guideline is based on the

DSM-N notion of a continuum of depressivedisorders from Uncomplicated Bereavementthrough Adjustment Disorder With DepressedMood to Major Depression, MelancholicType. This continuum is a notion based onFreud’s germinal work Mourning and Melancho-

lia.24 It is thus congenial to psychoanalysts. Italso recognizes that personality disorders may

impair the patient’s capacity to deal with de-pression. From this perspective, psychoanaly-sis represents inappropriate treatment forbereavement and other V-code problems,even when the patient meets criteria for ana-lyzability (see Figure 1). If, however, mourn-ing does not resolve within culturallynormative guidelines, the clinician fullyreevaluates the individual to decide whether a

psychiatric disorder interferes with this ordi-nary adaptive process or has been precipitatedby the loss.24� In practice, one leaves the dooropen to these V-coded patients to return if

mourning is inhibited or prolonged.

Mental health professionals may presentfor treatment as part of their education or to

enhance their therapeutic skills. They rarelycan endorse a true chief complaint, althoughthe prevalence of subclinical dysthymia in this

population2�28 steers many of these individu-als to endorse depression as their problem.Rather than isolate these cases, one asks thatthey endorse a chief curiosity in lieu of a chief

complaint and loops them back into the mainstream of psychoanalysis and psychotherapy.This maneuver allows us to monitor the qual-

ity of psychotherapies undertaken for training

purposes and makes the peer review proce-dure available to education committees fortheir special quality assurance work.

This guideline stresses the importance ofa full biopsychosocial evaluation. Correct phe-nomenological diagnosis is essential, but omit-ting early and conscientious assessment of thedynamic components of a case29 frequentlyleads to clinicians’ overlooking important as-pects of a patient All psychiatry, and particu-larly psychoanalytic psychiatry, seemshaunted by the DSM-II position that majordepression and so-called neurotic depressionare mutually exclusive.30 This colors theAmerican Psychiatric Association’s PracticeGuideline4 position on psychotherapy for ma-jor depression; it also influences the way olderpsychoanalytic colleagues think about de-

pressed people. It leads some clinicians to

overlook the power of mulhimodal treatment

for patients who function at a neurotic level,and it leads others to underutilize psychother-apy for patients with high-level personality

disorders when they present with a severedepressive disorder that clearly requires andresponds brilliantly to a biological treatment

Trial of Individual Medical Psychotherapy: Acourse of brief individual medical psychother-apy accomplishes several functions concur-

GRW 217


rently. It quiddy provides the patient with a

segment of psychotherapy. It allows the clini-

cian an opportunity to complete a detailedassessment of the case and to complete theinitial treatment planning process. For cases inwhich long-term psychotherapy or psycho-

analysis become options, it serves as a test ofthe patient’s capacity to work effectively with

the therapist in an insight-seeking mode.We reassess the patient quicidy after three

sessions of psychotherapy to verify that thecase is stabilizing. We abort the treatment andreevaluate the case if the patient’s condition isdeteriorating. This is also the point at whichwe first consider medication. The guideline

states clearly that psychophannacotherapy isan integral element of medical psychoanalysis,

and the procedure diagram shows points atwhich we might consider and administer this.

We know that many patients with major de-pression have a true neurosis3’ and respondwell to a combined approach.32 Several senior

colleagues nationwide informed me that thecombined approach has been state-of-the-artin their local group for some time. In an

unrelated survey, Doidge found that of 641psychoanalytic patients treated by 237 active

members of the American Psychoanalytic As-sociation, 92 (14.4%) were on an antidepres-

sant medication, and slightly more than half ofall patients who are treated concurrently withpsychoanalysis and pharmacotherapy were

medicated by their treating psychoanalysts(Norman Doidge, M.D., personal communi-

cation).At the completion of this module, some

patients may require no further treatment or

continuing psychotherapeutic management ofthe biological treatment Other patients maydisplay either disturbances sufficient to man-

date full reevaluation or indications for anintensive insight-seeking treatment This is a

good point for a pre-authorization review. Atthis lime one needs ordinarily to consider a

range of treatment options, but I noted thatpsychoanalysts tended to gravitate toward rec-

ommending psychoanalysis or a closely re-lated psychotherapy rather early in this

process. This represents a potential weak pointthat can be addressed by external pre-authori-

zation review. If psychoanalysis is determinedto be the preferred treatment, we go to a

further brief technical assessment and a clini-cal trial. This may be followed by a moredefinitive pre-authorization review based on

observations of the patient’s actual perfor-mance in psychoanalysis. The advantage ofthis approach is that we have early informationabout the patient’s need for and capacity to

work within this demanding modality, and wehave optimized the chances for success by

having corrected any underlying biological

imbalance through medication.

Trial of Psyc/zoana�5isis: This guideline followsthe 1975 consensus of the Baltimore and Wash-ington psychoanalytic colleagues that the

treating psychoanalyst should reevaluate a

case after 1 year to ensure the appropriatenessof the initial prescription. Formal reassessmentprovides an opportunity to rediagnose, to note

progress, and to identify and correct errors inthe treatment plan. It also allows patients an

opportunity to accept indicated medicationthat they may have declined earlier. After a

successful trial of psychoanalysis we continue

treatment and reassess periodically.

Progress: Patients demonstrate progress in

psychoanalysis in the way they work with the

analyst to achieve self-understanding and re-sume emotional growth.3 The guideline doesnot take a position with respect to the nature

of these events, leaving each clinician free to

define criteria that reflect his or her theoreticalviews. These subjective criteria are reflected

objectively in three places in the DSM-Ndiagnosis. The Axis V GAF score will risedramatically as patients confine their symp-toms to the psychoanalytic situation and thetransference neurosis consolidates, then risegradually as treatment goals are realized. Con-sequently, an external reviewer must guardagainst disallowing treatment based on an im-proved Axis V. Our knowledge of how psy-choanalysis works suggests that the failure of

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224 GUIDEUNES FOR PSYCHOANALYSIS

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Axis V to soar should trigger reassessment In

later phases, progress is confirmed objectively

by the disappearance of the Axis I disorderand by changes along Axis II that reflectgrowth in the structure of the patient’s person-ality; Axis II Cluster B disorders will be super-seded by Cluster C disorders. At termination,

ideally all psychosocial diagnoses disappear

and their biological components are in remis-

sion.

Complications: This guideline keeps us alertto the possibility that the patient’s condition

may worsen during treatment In cases of se-rious depression, worsening can cause a lethaloutcome.

We may view psychoanalysis and dy-namic psychotherapy as modalities that offerunderstanding. Their essential neutrality al-

lows patients to use insight to improve theirmental health or to perfect their mental disor-

det The negative therapeutic reaction is a

special class of complication in which theworsened condition may reflect technical

progress in the treatment This guidelinepresents an initial attempt to define a way inwhich the psychiatrist may evaluate suchcases and create an appropriate treatmentplan for each.

CASE ILLUSTRATIONS

The following two cases illustrate aspects ofdecision making in the treatment of depres-sion without (Case 1) and with (Case 2) the useof the practice guidelines.

Case 1. Wylie and Wylie32 reported the case ofa 39-year-old administrator who consulted a psy-choanalyst because she could not establish a satis-factory long-term relationship with a man. Shewas also anhedonic. She had struggled for manyyears with intermittent episodes of depressionthat were refractory to tricycic antidepressantsbut responded well to amphetamines. After an in-

itial assessment� the psychiatrist found that the pa-tient met thepublished diagnostic criteria foranalyzabtht� and instituted psychoanalytic treat-ment.

Eighteen months into a dassical psycho-analysis it was clear that the patient was unable to

grasp the special quality of transference related-

ness, she was depressed, and she continued to bereluctant to risk an emotional investment in thetherapeutic relationship. The history that had

been gathered in the course of analysis revealed asevere sensitivity to rejection and a prodivity forseWinjurious behavior. At this point the psychia-that prescribed a monoamine oxidase inhibitorand continued the psychoanalytic treatment

One month later, the patient spontaneouslyacknowledged transference feelings within theanalytic session. Soon thereafter she was able tocollaborate with the psychoanalyst to develop in-

sight; and 2 years later she had achieved her treat-ment goal& The patient continued to do well at a10-year follow-up visit (Harold W. Wylie,Jr.,M.D., personal communication).

This is one of the earliest published ac-counts of antidepressant medication used in

conjunction with classical psychoanalysis. Ap-plying the proposed guideline (Figure 2) retro-

spectively to this case, we note immediatelythat psychoanalysis was instituted without atrial of psychotherapy adequate to ascertainwhether the patient was able to work in an

insight-seeking mode. Having failed to estab-lish this point, the psychiatrist continued thepsychoanalysis without evidence of progress

and without consideration of pharma-cotherapy for 18 months. The psychiatrist dideventually come to understand the nature ofthe problem, reassessed the case, and imple-mented a treatment plan that resulted in a

good outcome in a short time.

Had these guidelines been available at the

time this case was treated, the psychiatrist

might have recognized early both the need to

ascertain that the patient could work in aninsight-seeking mode and the importance ofconsidering medication if the initial trial ofpsychotherapy proved inauspicious. Even ifhe and the patient had chosen to do onlypsychoanalysis, it is likely that his early find-ings would have set the stage for continuousassessment of progress and of the possible use

of medication. This process might have short-

ened the treatment by as much as a full year.

GRAY 225


Case 2. A 40-year-old scholar came to me for asecond opinion consultation at the request of the

treating psychiatrist, who questioned the appro-priateness of continuing psychoanalysis withoutantidepressant medication.

The patient had first consulted the psychia-trist 15 months earlier complaining of unpleasantfeelings compounded of anxiety and guilt thathad become increasingly intense over a period of2 years. He viewed them as a response to con-ificts related to a parent’s suffering and eventualrecent death after a long illness. Although he hadharbored similar guilt feelings subdinically foryears, they seemed to be experienced as back-ground noise that did not interfere with optimal

functioning. There had been a course of individ-

ual psychotherapy 20 years earlier in connectionwith discomfort over academic performance. Heexperienced it as helpful but incomplete.

When the patient first presented to the psy-

chiatrist,depression was the salient clinical find-

ing. He wept often and manifested disturbed

sleep patterns, anxiety, irritability, and poor self-esteem. The psychiatrist recommended Individ-ual Medical Psychotherapy (CPT 90844) at a

frequency of twice weekly; the prescription ex-plicitly included antidepressant medication. Thepatient declined the latter.

Three months later, when he had gained

some insight but did not achieve full symptom re-lief and did not seem to be well engaged in the

mourning process, the psychiatrist again called at-tention to the appropriateness of pharma-

cotherapy. This practice conforms to the

guideline for reevaluation of the treatment plan at

the completion of brief psychotherapy (Figure 2).The patient again rejected medication and aflirm-atively requested psychoanalysis. After careful as-sessment, the psychiatrist agreed. At this point,the plan met guideline criteria because it was de-veloped after appropriate reassessment. They be-gan work in this mode about 1 year before theconsultation. They were now at the time of the

major reassessment mandated by local guidelines

and recommended by this guideline.

The patient arrived precisely on time andsettled down to the interview after I made a briefexplanation of the function and scope of my in-

quiry. Pale, flawlessly groomed, and dressed in awell-cut charcoal gray suit, black shirt, tie, and

pocket handkerchief, black hose, and blackshoes, the patient appeared a picture of continu-ous, sophisticated mourning. His demeanor was

subdued and somewhat apprehensive. He sat di-redly opposite me in the consulting room and ad-

dressed my questions and comments slowly,carefully, and in some detail; yet he revealed

very little. He spoke in two voices. One was low-pitched, authoritative, and masterful. The otherwas higher in pitch; it bore faint traces of a Brit-ish academic accent, but the overall impressionwas of childish vulnerability. The latter voicedominated.

The patient fussed about the formal mental

status examination, insisting that the items weretoo difficult When I remarked quietly that a de-

mented individual was certainly not analyzable,he quickly tackled the problems, doing well onthose that required abstract thought He endorsedsuicidal thoughts in the past; these did not reach

the level of a plan. He also endorsed Irritability,forgetfulness, and fantasies of vengeance. He de-nied anhedonia and substance misuse The pa-tient denied ever having seen visions or heardvoices of absent persons; he also denied ideas ofuniqueness or of persecution. He had not faintedor had epileptic attacks, including “absences.” So-

cial judgment seemed good. Performance on two

formal tests of long-term memory seemed Im-

paired by poor concentration; short-term mem-ory seemed adequate.

DSM-IVDiagnorLc: Axis I: 296.21 MajorDepression, Single Episode, Mild; Axis 11:799.90Diagnosis Deferred; Axis ifi: No physical condi-tion that affects the mental status; Axis N: Deathof parent; Axis V: 55 Moderate symptoms of de-pression and anxiety and some difficulty in socialfunctioning.

The patient may have presented with a majordepression, single episode, severe without psychoticfeatures (DSM-N 296.23). The severity of the disor-der abated, but he still endorsed symptoms of amild major depression. It was not possible to diag-

nose a specific personality disorder in this single in-terview. It seemed likely that the anxiety hereported signaled the emergence of an Axis 11 disor-

der out of a previously stable and adaptive personal-ity style that faltered in response to the stress of the

parent’s illness and death.

Although psychoanalysis is very often thetreatment of choice in cases where the majortherapeutic effort must focus on the personality

(Figures 1 and 2), it was clear that after a year oftreatment the patient remained mournful. Accord-ing to the proposed guideline (Figure 2), a trial ofmedication had been indicated earlier and had

226 GUIDELINES FOR PsYcHoAr�LYsIs


become even more important because he hadmade inadequate progress without it In the con-

sultation, I explained to the patient that the pres-

ence of an Axis I disorder, even in subclinicalform, can and does interfere with the psychoana-lytic treatment of an Axis 11 disorder. Medical

psychoanalysis (CPT 90845) that includes psycho-pharmacology for the Axis I disorder has an ex-cellent chance of success in addressing thebiological and psychosocial aspects of the disor-

der in a coherent and definitive fashion. I sup-ported the treating psychiatrist’s prescription ofthis multimodal approach, recommending thecontinuation of medical psychoanalysis only if itinduded the medication component.

Discuss ION

The effort to establish expert guidelines for anew or revised health care system can lead to

conflict with clinicians because expert guide-

lines favor outcome research over clinical

inteffigence.33 Although outcome-based pa-

rameters have the advantage of their researchfoundation, they also have its disadvantages.

One is a reliance on statistical studies withproblematic methodology.34’35 Another is that

the present funding environment may have

influenced researchers to neglect inquiry intothe effect of definitive care over the lifetime ofan individual. A third is that because few

specific interventions have been studied, prac-

tice parameters based on outcome studies are

incomplete, and psychiatrists therefore en-

counter obstacles when they try to implementthem in daily practice.

Consensus-based practice guidelines aim

to codify the oral tradition in medicine. Theyare particularly useful in psychoanalysis be-

cause psychoanalytic education is grounded in

detailed discussion of single cases with a senior

teacher. Because they reflect actual practice,

they are readily accepted by clinicians.36

The development of such guidelines con-tains a risk of endorsing suboptimal treatment

choices. Two pathways are available to miti-gate this danger. First, one may use these

guidelines as propositions that will be tested in

future research. Second, if the consensus pro-

cess reveals an area in which a professional

group did not revise its clinical behavior inresponse to the emergence of new scientificinformation, its leaders may use the findingsof consensus studies such as this one to de-velop an educational strategy that targets theparticular defect

As a by-product, these guidelines define a

common ground for clinicians and lawyers.

Practice guidelines can support the colleaguewho is sued by providing dear statements aboutacceptable technique. l)etailed discussion of thissubject would require another paper.

These guidelines based on emerging clini-

cal consensus help us detect which individuals

in the large pool of patients who present with

a popular complaint that covers a wide spec-

trum of psychopathology require and may

benefit from psychoanalytic treatment The

guidelines remind us that many patients who

have a biological predisposition to depressionalso have serious neurotic conflict and that wemust look beyond medication and support to

substantive dynamic treatment for these indi-

viduals. Simultaneously, the guidelines helpwinnow out those patients whose ego struc-

tures cannot withstand the rigors of classicalpsychoanalysis or other intensive psychother-

apy. Eventually, such guidelines may form the

basis of economical systems of health care thatavoid arbitrary, clinically untenable limita-

tions on services.

A different version of this material was presented

at the American Psychiatric Association annual

meetin& San Francisco, CA, May 24, 1993. The

author is gratefulfor the encouragement and support

of the Committee on Peer Review of the American

Psychoanalytic Association Although this articlepresents some of the Committee’s work, the condu-

sions and opinions expressed are the author’s alone.

This article has not been endorsed by the American

PsychoanalyticAssociation, and it does not reflect its

official position. The opinions or o�sertions con-

tained in this article are the private views of the

author and are not to be construed as official or as

reflecting the views of the Department of the Army

or the Department ofDefense.

Gi�w 227


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