Professor Mikhail Reshetnikov, MD, PhD
The ECPP-President paper at the 6th ECPP-Congress (Rome, 6.10.2012)
New Approaches to Psychoanalytic Education and Training
Now let us make the fantastic supposition that Rome were not a human dwelling-place, but a mental entity with just as long and varied a past history: that is, in which nothing once constructed had perished, and all the earlier stages of development had survived alongside the latest.
Sigmund Freud. Civilization and its discontents
The epigraph to my paper is a well-known quote from Civilization and Its Discontents, where Freud speaks about history of Rome. Freud compares the Eternal City to psychic space, where the past co-exists with the present. We can feel his passionate love to Rome in this work. I would like to join him in that and to express my admiration for the Eternal City and my gratitude to our hospitable hosts.
In the end of my presentation I will return to this quote. And now, before I start speaking about new approaches to psychoanalytical education and training, I would like to briefly outline my vision of modern tendencies in psychotherapy and psychiatry, as these two spheres are closely connected.
Despite the fact that psychiatry and psychotherapy deal with the same subject, that is, human psyche, they haven’t come close to each other until recently. However, we can see some changes in this field now. From mutual reproaches in exclusively biological or exclusively psychological position we have come to attempts to understand each other. We can see the new tendency in the paper of Prof. Horst Kaechele and Prof. Anna Buchheim.
Let me give you some figures related to Russian experience to put you in the picture. There are 614 thousand practicing doctors in Russia, but nowadays - 25 years after legalization of psychotherapy in Russia - we have only 16 thousand psychotherapists, and about 24 thousand clinical psychologists. That is, in the area of somatic medicine there are 600 thousand practicing specialists, and in the area of mental health there are only about 40 thousand of them per 140 million of population.
It will be more understandable if I present these figures as a proportion of number of doctors to 10 thousand people. Russia is the fourth country in the world in number of general practitioners: 43 to 10 thousand people. But people are more frequently ill in Russia, and they die earlier than in some other countries. Average length of human life in Russia is 69 years; 64 – for men and 74 for women. It leads us to the question of quality of medical care. However, I think that this problem is caused not only by somatic reasons, but also by massive psychic trauma in result of the dissolution of the USSR in 1991. But in the area of psychic health the number of specialists in Russia is even more dispiriting: 2.7 specialists (doctors and psychologists) to 10 thousand people. At the moment we can see some manifestations of psycho-social crisis in Europe, so this might be not only Russian problem.
If we consider the data published by the World Health Organization that about 40% of patients who come to medical doctors do not need any medical help but need psychotherapy instead, we can understand that the imbalance reflected by these numbers is tragic indeed - first of all, for the patients. Let me stress that we have huge imbalance between psychotherapy and somatic medicine. Even if all medical doctors understand that 40% of their patients need psychotherapy and encourage them to seek help, we won’t have enough resource to help these patients. It is a great political and strategic problem. I will return to this problem later.
Let me tell you a couple of words about crisis of psychiatry. The main cause of this crisis, as I think, is the fact that this approach was based on biological concepts which haven’t passed the test of time and haven’t been proved by modern methods of research.
There are many reasons for that, but I will mention only the most important of them:
- No biological tests or markers have been found which allow convincingly diagnosing psychic disorders.
- Contemporary genetic research, including research of schizophrenia, also hasn’t brought the expected results (while psycho-social factor of “schizophrenogenic family” has become accepted even by psychiatrists).
- We know that, in contrast to other medical disciplines, psychiatric treatment is neither etiological nor pathogenetic.
- Psychiatric treatment cannot be verified by principles of evidence-based medicine.
- Long period of psychopharmacological trend in treatment of psychiatric patients showed that it doesn’t lead them to real mental health.
Moreover, contemporary research showed that psychotherapy influences the exchange of neuromediators in the same way as serotonin reuptake inhibitors do. But psychotherapy does not have any dangerous side-effects, including damage to the internal organs and the reproductive system, and it doesn’t lead to intellectual and emotional reduction. That is why some American colleagues express their opinion that psychopharmacology has become “a treatment for the poor people”, while educated and wealthy patients prefer psychotherapy.
The crisis touched even classification of mental disorders, which had seemed unshakable, but which psychiatrists themselves began to consider a source of dehumanization of their profession.
Many psychiatrists have noticed that through study of a patient’s problems is substituted by the list of symptoms, which is necessary just for statistics, because this diagnosis is neither etiological nor pathogenetic.
We all know that symptoms in psychopathology and symptoms in somatic medicine have absolutely different sense. But majority of our colleagues in psychiatry examine patients and perceive their symptoms as if they are typical somatic ones.
I would like to remind you that all modern psychiatric concepts are based on hypotheses, and originally these hypotheses were psychological ones, including classification of mental diseases by Kraepelin. It was typically behavioural classification, that is, psychological one.
Now in some countries, in Japan for instance, psychiatrists have started to reject DSM and to gradually formulate a psychological classification of mental disorders (let me stress it: not diseases, but disorders). Thus, schizophrenia is called “syndrome of dis-regulation of integrative processes”; dementia is “gross cognitive disorder”; delusion is “unshared dysfunctional ideas”. Japanese colleagues suppose that this approach is less stigmatizing for the patients and helps them to get more adequate perception of their condition. Moreover, it allows shifting from the “paternalistic model” of psychiatry to another model, which is called “the model of informative consent”.
Many psychotherapists and even some psychiatrists in Russia have rejected the traditional notion of “psychiatrically ill person” as a humiliating label and begin to use such terms as “a client”.
In some countries, including Russia, psychiatry as a profession has become less prestigious, and at the same time psychotherapy has become more popular. Psychiatrists tend to explain it by popularization of anti-psychiatry and its ideas. But independent experts connect this to growth of education and culture of people who have started to pay more attention to their psychic health and who don’t like side-effects of intense psychopharmacological treatment. Everybody knows that information about these side-effects can be easily found on the internet, where these topics are very popular.
I have already dared to wonder - whether psychiatry is a medical specialty at all? Medicine deals with human body. Nobody will object, as I hope, that psyche and personality cannot be equated to body. That is why medical models are not appropriate for this area. By the way, even my question about psychiatry as a medical specialty was perceived as something obscene.
I would like to mention a few more problems. One of them is general tendency to shorten the time of inpatient treatment and to decrease the number of inpatient places, including psychiatric ones. It means that patients are transferred to outpatient treatment.
From this point of view, it is interesting to consider the conclusions made by our American colleagues, that the majority of aggressive actions - including homicides and suicides - have been recently committed by those who were taking antidepressants on outpatient basis, that is, uncontrollably.
According to the European reports of 2011, number of people with mental disorders in the European Union (pre-clinical and clinical level) is more than 160 million.
It is one third of the European population. I think we have the same situation in Russia, so it is our common problem.
And it is more than the number of patients with cardiologic and oncologic diseases in these countries taken together. The European Parliament knows these data very well. Maybe they, as non-specialists, consider it normal, just a matter of fact, like the environmental pollution. But probably we, as professional community, should speak about this problem more openly and more competently, shouldn’t we?
We have to admit that in the new century we have faced a lot of new questions:
- Do we have enough resource for providing these millions of people with qualified psychiatric, psychotherapeutic and psychological help?
- Do we have adequate approaches to psychopathology at all?
- Which adequate decisions and reforms should be undertaken in the nearest years to meet our patients’ need of understanding, compassion and help?
Here is only one more or less positive conclusion: none of us will be left without patients.
That is why, if we really care about patients, there is no ground for professional competition, and we need to take steps towards cooperation between all specialists of helping professions, first of all, in order to critically review the established scientific, organizational and methodological approaches to mental disorders and to develop new ones, which will be more appropriate for our time.
And now I’ll speak about new approaches to psychoanalytic education and training in the modern world. These approaches are very closely connected with the problems I have mentioned. Modern social life is changing very quickly, and the speed of change increases from year to year.
People are more mobile now: they change their marital partners, their occupations, place of living and profession, their countries; very often they feel themselves under pressure of time and flood of information, sometimes they feel exhausted and lose emotional connections and – they need psychotherapy…
We have to recognize all these things and to create new approaches to our profession, to our professional education and training, and to our patients’ demand. I hope we, the ECPP members, have been already doing it and will continue this work in future.
Nine years ago we founded a new organization, the European Confederation for Psychoanalytic Psychotherapies. It was not just a new international society, but an organization of a new type.
Many of you know our new approaches, so I will speak about them very shortly.
We rejected a conservative "monastery system" of training, which is prevailing in some international psychoanalytical societies (and which was compared by Otto Kernberg with "consecration"), and we tried to overcome the split between different psychoanalytical societies.
We declared a new principle of integration for psychoanalytical psychotherapists. I quote: "Everybody who was trained in accordance with European standard and who works with transference and resistance is our colleague".
We were one of the first organizations in the world, which recognized professional training, received in other reputable societies, and we took some more innovative decisions. I’ll give the list of these decisions in the end of my paper.
These ideas were the basis of our enthusiasm and our unity, and the results of our effort were even more positive than we had expected.
From 2003 to 2012 the number of individual members of the ECPP has become 30 times bigger. The number of applicants for the ECPP-certification is growing from year to year.
These numbers deserve our special attention in context of international crisis in psychoanalysis and decrease in number of candidates in the oldest and the most reputable psychoanalytical societies in the world. As you know, this problem has been discussed in many rather pessimistic articles.
I will quote a short extract from the paper "Project for Coming Years" which was given at the IPA Congress in Chicago in 2009 by Dr. Ch. Hanly, the IPA President-elect:
"... But the trouble now is that relatively few analysts have as many analytic patients as they would like… Too many analysts have to supplement their income with the practice of psychoanalytic psychotherapy or of their pre-psychoanalytic professions. Analysts need more analytic patients and the community needs more analysts. Our institutes need more young candidates”.
I add that, as I know, most Western Psychoanalytic Institutes have no more than 10 candidates per year. We receive as minimum 10 times more candidates every year.
I will also remind you a phrase of Dr. Nancy MacWilliams, which she said at the NAAP-congress in the United States: “maybe psychoanalysis will die earlier than those people who once fell in love with it”.
I am sure you’ve read one of the recent articles by Otto Kernberg. It is called “Suicide prevention for psychoanalytic institutes and societies” (2011). I will quote just the first line of this paper: “Any effort to change the condition of a failing psychoanalytic society is likely to generate intense anxiety, frequently expressed as desperate clinging to “standards”.
Many authors of papers on the subject have noticed that psychoanalytic community is getting older and older. We don't have such problems. The situation is just the opposite. We are a very young and fast-growing organization. Average age of members of our organization is 42 years.
On the one hand, it means that we are on a right way, and we meet the social demand of those who have decided to devote their lives to psychoanalysis. On the other hand, there are many difficulties in transmission of clinical experience and high level of professional training.
I would like to repeat and clarify this idea. We had not expected such a rapid and significant increase in number of the ECPP-members, although the number of experienced specialists in our organization is not sufficient yet. Now we have our national branches and national representatives in 18 European countries.
For some time we had insufficient growth of membership in Western countries. But in the last year we have got more than 30 new members from France. I am sure that the situation will gradually change in other Western countries, in which there are old and reputable psychoanalytic organizations.
We openly declare that we are interested in clinical experience of these old societies and we are open for cooperation. But we have intentionally chosen a different way for development of psychoanalysis.
I’ll allow myself to express one more idea: Western Europe was and still is the center of psychoanalytical thought, but the center of development of psychoanalysis in this century is moving to the East.
In 2013 our new organization will celebrate its 10th anniversary; it's just first decade of its life. As we know, "after the first hundred years life gets easier"; I hope it does.
During the recent decade we have implemented a few important reforms of psychoanalytical education and training. They were not always understood and approved by all our colleagues.
But we kept going our way, revising the 100 years of international psychoanalytic experience, overcoming resistances and conservatism and suggesting new approaches to almost any aspect of psychoanalytical education, training and practice.
I have mentioned the paper by Professor Otto Kernberg. I would like to stress once again his main idea: we need to remove bureaucratic procedures from psychoanalytic education and training. That’s exactly what we are doing.
What have we already done in Russia and to some degree in the ECPP?
1. Psychoanalytic education has become independent from psychoanalytic training (as a result, for example, in our Psychoanalytic Institute in Petersburg we have 630 students, and only 15 - 20% of them begin their personal training but others attain good theoretical knowledge in psychoanalysis).
2. Candidate himself chooses his analyst and his supervisor. We have suggested less intense setting for training analysis – minimum 2 sessions per week – and we have seen that it hasn’t made psychodynamic less efficient.
3. After completing European Standard, a candidate is allowed to stop his training (but in reality it happens only in 10% of the cases. Let me stress that 90% of candidates continue their training, and sometimes their number of hours is twice bigger than standard and even more – but it is their own choice, and it is absolutely different ethic situation).
4. We encourage candidates to start their practice as early as possible: in social sphere, kindergartens, schools, in counseling etc., and then in psychoanalytic psychotherapy.
5. We have rejected the idea of age requirements for beginners (sure, it is better, when a candidate has marital, sexual and general life experience; but if we go this way, why shouldn’t we require him to have experience of depression or schizophrenia?).
6. We have discarded the mistaken idea that the longer is one’s training, the more successful will be his practice. We rely upon the fact that a candidate wants to get a profession, and we should give him such an opportunity without forcing him to stay our patient for many years. Let me remind you that the first Freud’s followers had minimum of analysis, but their investment in development of psychoanalytic theory and practice was invaluable.
7. We have minimized the difference between psychoanalysis and psychoanalytical psychotherapy, as in any case, even if we recognize the difference between them, the work is based on psychoanalytical theory and its principles.
8. We have widened the spectrum of pathologies which psychoanalysis can work with, including psychotic disorders.
9. We have made psychoanalysis more open discipline. I mean that psychoanalytical knowledge became available to a larger group of people, not just to “a clan of chosen”.
10. We have developed new and wider contacts with other modalities of psychotherapy and with related fields – philosophy, sociology, pedagogic and other modern sciences.
We were also one of the first who began to work with our patients by phone and by skype, but it is recommended only after a few preliminary personal meetings with them. It is hard to believe that it is rational for a patient to waste 2 hours in traffic jams to get to his 50-minute session.
We also organize group supervisions, psychoanalytical seminars and lectures by skype. It is not the full list of new approaches, but the most important of them.
I would like to stress once again that it was the result of our collective effort during all these years. But it is only beginning. We have a lot of difficult tasks and I am sure we’ll meet a lot of new challenges on this way. But I have no doubt that we have chosen the right way.
I described these approaches for the first time in my paper What can we learn from the West and what should we better avoid? (2004). At that time the paper was ridiculed by many Western colleagues as well as specialists from Eastern Europe. There is no doubt that many of them will perceive these approaches critically even now. It is only natural, considering the fact that professional identity of many our reputable colleagues was influenced by classical principle of not mixing the gold of psychoanalysis with the copper of psychotherapy. I would like to ensure my colleagues that we do not mix them too and stay devoted to psychoanalytical paradigm.
In the conclusion I would like to return to Freud’s metaphor of Rome and to his idea of the past co-existing with the present. It is a universal phenomenon, and it is equally true for the Eternal City and for psychoanalysis. New ideas in psychoanalytical education and training were not developed in emptiness. That is why together with implementing these innovations we should express our immense respect to previous generations of psychoanalysts, to our origins and roots. We do not destroy what was done before; we give it a new impact for development.