State of the psychoanalytic nation: Switzerland

Abstract

Psychoanalytic psychotherapy holds a prominent place in the Swiss health care system. In addition to the rich history of psychoanalysis in Switzerland, the dual qualification in psychiatry and psychotherapy for medical specialists and the recent federal recognition of the title of psychologist-psychotherapist support the continuation of rigorous psychotherapy training in mental health institutions with the patients suffering the most. In Switzerland, there is a lively discussion on the treatment modalities in different forms of talking psychotherapy, in a perspective of integration with other dimensions of psychiatric care. New models of care have emerged, inspired by psychoanalytical psychotherapy, bringing hope to the discipline because they are adapted to the difficulties of our patients and to the demands of the contemporary world. In parallel, exacting training in classical psychoanalytical models continues to be practiced and fostered.

Keywords:

• psychotherapy
• psychoanalysis
• training
• health-system
• integration

Psychotherapy, particularly psychoanalytic psychotherapy, occupies a prominent place in the Swiss health care system. In addition to the rich history of psychoanalysis in our country, one should note a particularity that strongly supports psychotherapy in Switzerland: the degree of psychiatrist is a ‘dual title’ of specialist in psychiatry and psychotherapy. This dual title implies a dual training, equally exacting in these two fields, and supports a combined practice in which these two aspects are integrated at the patient’s bedside, within both psychiatric hospitals and private practice. Therefore, psychotherapy is widely taught and supported for medical doctors and psychologists in psychiatric care settings, and a long-standing reflection has developed in Switzerland for thinking about patients’ difficulties with this combined perspective.

The fact that psychotherapy is part of the training curriculum for psychiatrists gives strength to its teaching and its presence in university training environments, resulting in a long and fruitful tradition of connections among medical faculties, psychology faculties, and local psychotherapy societies. This particularity, with its ideological implications being of primary importance, probably explains why psychotherapeutic treatment continues to be reimbursed in Switzerland by the so-called ‘basic’ health insurance, at least for the first 40 sessions, following the latest health insurance reform. Recently, the Swiss parliament has again supported access to psychotherapy by providing access to reimbursement through the so-called ‘basic’ health insurance for outpatient psychotherapy delivered by psychologists and psychotherapists, which, so far, has been only for medical doctors.

As in other countries, psychoanalytic psychotherapy has suffered from its initial hegemony and perhaps therefore from its arrogance, but it has also experienced initial difficulties in developing convincing psychotherapy offers adapted to contemporary needs, ‘in the shadow’ of psychoanalysis. There was a recent period when psychoanalysis was still very powerful in psychiatric institutions, especially in the French-speaking part of Switzerland, leaving little room for other psychotherapies and thus perhaps showing difficulty in renewing itself and opening up to the social evolutions of the modern world and its demands. We are now in a period when psychoanalytic psychotherapy is ‘catching up’ and coexists in institutions and in training with family therapy, with the latter still gaining influence. Indeed, the cognitive-behavioral therapy (CBT) school has been able to gain ground by being very concerned about demonstrating its effectiveness and by profiling, as best as possible, an offer that meets the population’s mental health needs.

The complexity persists in the articulation – always under discussion and never obvious – between psychoanalytic psychotherapy and psychoanalysis. One way of articulating these two elements is to say that in Switzerland, training takes place in two stages: while psychoanalytic psychotherapy training takes place in health care institutions, psychoanalysis training takes place within the curricula offered by psychoanalytic societies, in a second stage of deepening. Another way of considering this articulation is to propose new psychotherapeutic care offers, profiled according to the needs of society and patients and drawing inspiration from the vast field of psychoanalytic psychotherapy. Finally, there is the method of integrating psychiatric and psychotherapeutic reflections, ‘at the patient’s bed,’ and of reflecting on psychoanalysis, thought of as one of the declensions of an available psychotherapeutic treatment.

Access to talking therapies within the national health system

Currently, psychotherapy is reimbursed in Switzerland by the compulsory health insurance (Loi fédérale sur l’assurance maladie, LAMal). The first 40 sessions of treatment are covered, and the psychiatrist must justify the extension of treatment beyond 40 sessions. The dual qualification and the integration of psychotherapy into psychiatrists’ training and routine clinical practice have affected the conditions for reimbursement of psychotherapy. However, this issue has always been debated. The difficult delimitation between medical psychotherapy and personal development and the generally high cost of psychoanalysis but also the lack of knowledge among insurance companies about the nature of psychiatric care have contributed to a laborious dialogue among doctors, insurers and government representatives.

Even though psychotherapy is part of official psychiatric treatment, its recognition by the insurance system has not been easy. An initial rule on reimbursement dates from the 1970s. Paradoxically, it excluded ‘depth psychology,’ an explicit reference to psychoanalysis. During the revision of the TARMED pricing system, the majority of psychiatrists and psychotherapists were opposed to a distinction between psychiatric and psychotherapeutic services. The main fear was that the reimbursement for psychotherapy would be differentiated downwards from that for psychiatric treatment.

Even more recent was the major revision of articles 2 and 3 of the Ordonnance sur les prestations ambulatoires de soins (OPAS), which came into force in 2006 (Swiss Federal Department of Home Affairs, 2006). Without being able to distinguish psychiatric services from psychotherapeutic treatments in invoicing, the state wished to give insurers the means to control the prescription of psychotherapy. In order to do so, the revision of the OPAS stipulated that psychotherapy should be reported before the 10th session and that a report justifying the treatment’s possible extension should be submitted every year. There was an immediate outcry, from both doctors and patients’ associations, in particular because of a consultation procedure that was considered minimalist and cavalier (Despland et al., 2006; Despland, 2007). This measure was seen as a takeover by the insurers, with the support of the state, of the professional’s clinical judgment. Finally, after 2 years, the state modified the ordinance and abandoned the requirement to announce the tenth session (Swiss Federal Department of Home Affairs, 2010).

Paradoxically, this measure has had positive effects, from the point of view of the recognition of psychotherapy:

• The OPAS offers an explicit definition of psychotherapy, distinguishing it from other forms of psychiatric treatment:

The designation ‘psychotherapy’ applies to therapies treating psychic and psychosomatic illnesses that are based exclusively or primarily on oral communication, systematic reflection, and an ongoing therapeutic relationship, that are based on a theory of normal and pathological behavior as well as on an etiological diagnosis, that provide for regular, planned sessions, and that have a defined therapeutic goal. (Swiss Federal Department of Home Affairs, 2006)

• The pressure put on psychotherapy by the state has made it possible to publicize and widely disseminate scientific data on the effectiveness, cost effectiveness, and appropriateness of psychotherapy. A report has been issued by the Department of Psychiatry at the Lausanne University Hospital, which reviews these issues within the context of the application of the OPAS (Despland, 2007).

For the time being, the exploration of the therapeutic effects of psychotherapies has instead strengthened their position, including in the field of long-term psychoanalytic psychotherapies (Leichsenring & Rabung, 2008).

Brief history of the development and place of psychoanalytic psychotherapy in the health care system

Medical psychotherapy

The recent history of psychiatry and psychotherapy in Switzerland is both rich and complex (Despland & Berney, 2012; Fussinger, 2005, 2008). Psychiatry has been a compulsory part of the federal medical examinations since 1888. In 1931, the Swiss Medical Association (FMH) adopted a regulation on specialist titles. In contrast to many European countries, a professional association – and not the state or medical schools – regulate this field. In addition, all hospitals are officially recognized as training institutions based on precise but open specifications. More generally, there has been strong continuity between inpatient (clinics) and outpatient (policlinics) services, between university and nonuniversity institutions (cantonal and regional hospitals), and between public and private psychiatry.

In 1935, the first meeting of Swiss psychotherapists was organized in Zurich. It mainly brought together psychoanalysts from the main currents of the time: Freudian, Jungian, Adlerian, and Daseinsanalysis. During a debate, Walter Morgenthaler defended the creation of a commission within the Swiss Society of Psychiatry (SSP), while Carl Gustav Jung proposed the autonomy of psychotherapy from medicine and psychiatry, emphasizing the greater competence of psychologists in this field. This conflict finally led to the creation of two groups: the Swiss Society of Practical Psychology on the Jungian side and an ad hoc commission within the Swiss Society of Psychiatry. In 1948, this latter commission became the Swiss Medical Society of Psychotherapy (SMSP).

The following period was marked by two SMSP initiatives, with the support of the SSP. Firstly, a request was made to the faculties of medicine and to the cantonal authorities to make psychology and psychotherapy education compulsory during medical studies. Secondly, the development of policlinics was advocated to facilitate the integration of psychotherapy in treating patients with limited financial resources. These discussions led to a revision of the specialist regulations. Pierre-Bernard Schneider, then director of the University Psychiatric Policlinic of Lausanne (PPU), proposed the creation of a subspecialty of psychotherapy within psychiatry. Although initially accepted, this proposal was cancelled by the directors of psychiatric establishments because of formal defects. In the end, the dual title of psychiatrist and psychotherapist was retained and is still in force.

Alongside discussions on training, the practice of psychoanalytic psychotherapy has been influenced by the evolution in the models of care delivered in public psychiatric institutions. As in most European countries, each at their own pace and within their political contexts, Switzerland decreased the number of hospital beds and correlatively developed outpatient clinics and liaison psychiatry (Despland & Berney, 2012).

This movement of de-institutionalization was facilitated by a growing interest in the psychotherapy of schizophrenic patients and the greater involvement of families in treatment, notably at the Lausanne University Hospital by Christian Müller (1955); Müller (1983, 1985) and in German-speaking Switzerland by Gaetano Benedetti (1987). This interest in the psychotherapy of psychosis has continued in Geneva (Andreoli et al., 1991) and in Lausanne (Berney et al., 2014; Söderström, 2015). The participation of R. Diatkine as a co-author in the book by Andreoli et al. (1991) illustrates the mutual influence among French-speaking psychoanalysts in the development of psychoanalytic psychotherapy within the health care system.

The training regulations have been revised several times since 1961. The latest revision was recent, dating back to 1 July 2009 (Foederation Medicorum Helveticorum, 2009). One of the major characteristics of this new curriculum is that it reinforces the psychotherapy training in the strict sense, with higher requirements than those of the previous regulation.

Psychiatry and psychoanalysis

Linked to the creation of the dual title, the condensation between psychoanalysis and medical psychotherapy had effects in the following decades. We can mention some significant aspects of this (Despland, 2012):

• This training model has long favored a certain passivity by the psychotherapist in training: a psychiatrist in training swam in the psychoanalytic bath from the moment they were hired in a public psychiatric institution.

• In terms of personal experience, the use of the standard treatment progressively has become marginalized. There are many reasons for this, but this movement has also been favored by the fact that medical psychoanalysts have accepted young colleagues for treatment at one or two sessions per week, face to face and under the third-party payment system.

• Simultaneously, the conditions for admission into the Swiss Psychoanalytic Society (SSPsa) remained very restrictive, specifically aimed at training on practicing high-frequency psychoanalytic treatment, and many experienced the conditions as opaque and arbitrary. A reaction within the SSPsa was aimed at preventing psychoanalysis as such from being diluted too much or even from being confused with psychoanalytic psychotherapies practiced in psychiatry.

For all of these reasons, the number of applications to the Swiss Psychoanalytic Society clearly dried up between 1980 and 2000 (De Coulon & Nobs, 2001); not only were there few candidates, but many of them remained confined to this status. Many psychiatrists turned to other modes of training in psychoanalytic psychotherapy.

How to become a psychoanalyst practitioner in Switzerland

Currently, in 2021, several training courses coexist. Two are subject to a federal title: psychiatrist psychotherapist and psychologist psychotherapist. The others are required by the various psychoanalytic societies (in the broadest sense) to be recognized and become a member of that society.

First steps of institutional and university training

Specialist title in psychiatry-psychotherapy

Obtaining the title of FMH specialist in psychiatry-psychotherapy is governed by the postgraduate training regulations of 1 July 2009, issued by the Swiss Institute for Medical Education (ISFM). The regulations state, ‘psychiatric-psychotherapeutic approaches include medical interviewing, integrated psychiatric-psychotherapeutic treatment (IPPT), psychotherapy in the strict sense, pharmacotherapy and other biological approaches as well as social therapy.’ (Foederation Medicorum Helveticorum, 2009, p. 3). Furthermore, ‘Postgraduate training in psychotherapy takes place within the framework of an integrated project … Throughout the specific postgraduate training, care must be taken to maintain a balance between psychiatric and psychotherapeutic elements.’ (Foederation Medicorum Helveticorum, 2009, p. 3). The trainee also must have validated theoretical training in psychiatry (240 hr), including a mandatory introduction to the one of the three axes of psychotherapy (analytic, CBT, or systemic; 180 hr), and finally credits for deepening one’s psychiatric-psychotherapeutic knowledge (180 hr).

The candidate also must obtain supervised credits: 150 hr of supervised integrated psychiatric-psychotherapeutic treatment (IPPT), 150 hr of psychotherapy in the strict sense, and 30 hr of postgraduate training supervision. Specifically, ‘The 150 hours of psychotherapeutic supervision refers to a minimum of 300 attested psychotherapy sessions, with at least two therapies comprising a minimum of 40 sessions each.’ (Foederation Medicorum Helveticorum, 2009, p. 6).

Following other requirements, which we will not detail here, the candidate must then submit to two successive exams: an exam by MCQ determining their acquisition of knowledge on psychiatry and psychotherapy and then a dissertation presenting a treatment that is to be written and then presented before a jury of peers. Notably, in these two examinations, the candidate’s knowledge and skills are judged in both the psychiatric and psychotherapeutic dimensions.

Title of psychologist psychotherapist

The federal title of psychologist psychotherapist can be obtained through training courses in the various fields of psychotherapy, which must be accredited by the Federal Office of Public Health. The criteria for this training are described in the Federal Department of Home Affairs ordinance on the scope and accreditation of postgraduate training courses in the psychology professions (AccredO-LPsy) of 25 November 2013 (Status 15 December 2020).

The training consists of 500 units of theoretical and practical training, which is divided into five points:

• clinical practice: lasting at least 2 years at 100% in a psychosocial institution, including at least 1 year in an outpatient or inpatient psychotherapeutic-psychiatric care institution

• individual psychotherapeutic activity: at least 500 units, with at least 10 cases treated, supervised, evaluated and documented

• supervision credits: minimum 150 units, of which at least 50 must be in individual sessions, only in the chosen axis

• personal therapeutic experience: minimum of 100 units, at least 50 of which must be in individual sessions

• additional units of supervision or personal therapeutic experience: a minimum of 50 additional units of supervision or personal therapeutic experience, depending on the orientation of the postgraduate program

The accredited training programs organize exams to check the candidate’s acquisition of theoretical and practical knowledge. A final examination is also planned, allowing access to the title.

Training courses of the Swiss societies of psychoanalysis and psychoanalytic psychotherapy

Swiss Society of Psychoanalysis (SSPsa)

The SSPsa focuses its activity on high-frequency psychoanalytic treatments. It is one of the component societies of the International Psychoanalytical Association (IPA) and a member of the European Federation of Psychoanalysis (EFP). Founded in Zurich in 1919, it has undergone various restructurings over the course of its development, including a split in 1977 leading to the independence of the Psychoanalytic Seminar of Zurich (PSZ; see below).

The SSPsa carries out its activities in collaboration with six regional training centers, in Basel (Psychoanalytisches Seminar Basel), Bern (Sigmund-Freud-Zentrum Bern), Geneva (Centre de Psychanalyse Raymond de Saussure), Lausanne (Centre de Psychanalyse de Lausanne), Lugano (Seminario Psicoanalitico della Svizzera Italiana), and Zurich (Freud-Institut Zurich). Through these centers, the SSPsa is also interested in training on psychoanalytic psychotherapy, within the framework of certification courses organized either directly by the regional center (Postgraduale Weiterbildung in Psychoanalytischer Psychotherapie of the Freud-Institut Zurich in Zurich) or in collaboration with other bodies, particularly universities and/or public health services and the regional sections of the European Federation for Psychoanalytic Psychotherapy (EFPP; see below) in Basel (Ausbildungszentrum für Psychoanalytische Psychotherapie), Geneva and Lausanne (Formation Continue Universitaire en Psychothérapie Psychanalytique), and Lugano (Scuola di Psicoterapia Psicoanalitica di Lugano).

High-frequency psychoanalytic training is conducted only within the SSPsa and its regional centers. To be admitted to the psychoanalytic training, one must have undertaken three to five sessions of personal psychoanalysis per week with a training member or an ordinary member of the SSPsa or the IPA; have a university degree; and have worked for at least 1 year in a psychiatric service. The training requires validation of psychoanalytic treatments conducted under supervision for at least 2 years, as well as the completion of theoretical and clinical courses and seminars. Two validated supervisions are required for training in adult psychoanalysis, or four for the specialization in child and adolescent psychoanalysis, including one adolescent analysis and one child analysis. The evaluation of this training gives access to the status of associate member of the SSPsa and member of the IPA. Additional clinical and theoretical training criteria govern access to the status of ordinary member, whose analyses can be considered valid for access to psychoanalytic training, and then of training member, who is entitled to supervise analysis. In addition to its collaborations in psychoanalytic psychotherapy training, the SSPsa has also been involved in interdisciplinary dialogue and the promotion of research for several years.

Psychoanalytical Seminar Zurich (PSZ)

The PSZ is not part of the IPA and follows a critical tradition towards institutionalized structures. Like the SSPsa, the PSZ trains on high-frequency psychoanalysis with adult, adolescent, and child patients and promotes the development of psychoanalysis, but its procedures for validating training are less formalized (up to now by self-authorization; formalization is under discussion among some members). Training requirements are similar but less strict: personal psychoanalysis of 3–4 hr per week with a recognized psychoanalyst; practice of two high-frequency psychoanalyses under the supervision of experienced analysts; theoretical, technical, and clinical seminars; and participation in intervision groups.

The PSZ also collaborates with the Freud-Institut Zurich for the training in psychoanalytic psychotherapy. This program targets the postgraduate FMH qualification of psychiatrist-psychotherapists and certification by the FOPH for psychotherapist psychologists.

European Federation for Psychoanalytic Psychotherapy (EFPP)

The EFPP represents the interests and development of psychoanalytic psychotherapy in the public sector and in private practice. It was founded in London in 1991. Its aims include anchoring psychoanalytic treatment and knowledge in the public health sector and making analytical psychotherapy accessible to everyone in need of psychic care. EFPP Europe and its branches aim to provide a platform for exchange between psychotherapists, guarantee the quality of postgraduate and continuing education in the field of psychoanalytic psychotherapy, and promote the development of research projects. In Switzerland, German-, Italian-, and French-speaking groups are present under the umbrella of EFPP Switzerland. It is the only association for psychoanalytic psychotherapy that brings together doctors and psychologists. Depending on the course of study, one can become a member in training, a member, or a certified EFPP psychotherapist member, which allows one to be an EFPP supervisor and trainer (European Federation for Psychoanalytic Psychotherapy, 2021a).

The EFPP groups in Switzerland do not offer their own training programs, but they are involved in training psychotherapists. Thus, EFPP Suisse Romande actively participates in the university continuing education in the Universities of Lausanne and Geneva. It has offered conferences open to the general public since 2014 and training modules in psychotherapy since 2015 (European Federation for Psychoanalytic Psychotherapy, 2021b). Under the aegis of EFPP-ARPAG, in collaboration with members of the Geneva and Lausanne centers of the SSPsa, EFPP and ARPAG (see below) propose 4-day training modules focused on the practice of psychoanalytic psychotherapy. The modules are intended for psychotherapists in training or who have already been trained (psychologists and physicians). For psychotherapists in training, the objective is to familiarize them with psychoanalytic conceptions of the psyche and of treatment based on concrete clinical contexts. For experienced psychotherapists, the exchanges offer an opening into points of view complementary to their own and a deepening of their theoretical and clinical reflections. This training is recognized for 32 continuing education units, or as a free module, within the framework of the university continuing education program in psychoanalytic psychotherapy.

Association Romande pour la Psychothérapie Analytique de Groupe (ARPAG)

The ARPAG, a member association of the international EFPP, aims to bring together and support the collaboration of psychotherapists practicing psychoanalytic group psychotherapy or psychoanalytic psychodrama. It proposes the development of research and training in this field, and conducts exchanges with other Swiss or foreign societies pursuing similar goals (Association Romande pour la Psychothérapie Analytique de Groupe, 2021). In order to promote the practice and development of psychoanalytic group psychotherapy in French-speaking Switzerland, the ARPAG offers a 2-year training cycle as well as complementary training courses given by its members (Association Romande pour la Psychothérapie Analytique de Groupe, 2021). ARPAG offers a training course in the field of group psychotherapy and psychodrama, aimed at trained psychotherapists or those in training who have personal therapeutic (Association Romande pour la Psychothérapie Analytique de Groupe, 2021).

Swiss Association for Child and Adolescent Psychoanalysis (ASUPEA)

The ASUPEA aims to promote Freudian, post-Freudian, and contemporary psychoanalytic thought in the service of psychoanalysis and analytical psychotherapy for children and adolescents experiencing difficulties. It collaborates with the European Society for Child and Adolescent Psychoanalysis and maintains close relations with the SSPsa. Its activities traditionally include scientific days and a continuing education or postgraduate program in the form of annual modules (Swiss Association for Child and Adolescent Psychoanalysis, 2021).

Association Suisse Romande de l’EuroFédération de Psychanalyse-New Lacanian School (ASREEP-NLS)

ASREEP-NLS represents the Lacanian orientation of psychoanalysis. It was created in January 2000, within the framework of the Ecole Européenne de Psychanalyse-Développement, after having existed under the name Lausanne Circle since 1993. In 2003, the Ecole Européenne de Psychanalyse-Développement, became the New Lacanian School (NLS), and ASREEP was declared an affiliated society and became the Swiss representation of the World Association of Psychoanalysis. Its goal is to promote psychoanalysis and its applications, as taught by Jacques Lacan and his successors and as applied in clinical work in psychiatry and in any space opened up by a request addressed to a psychoanalyst. One can become a friend or a member, through a procedure based on conversations with two members of a board which is renewed every 2 years, as well as coordination with the Executive Committee of the NLS. ASREEP provides information, through its website, on all of its training activities, such as congresses, seminars, conferences, workshops, and small working groups (cartels). Any training acquired (analysis, supervision, seminars, congresses, etc.) is sanctioned by a commission (the Group for Continuing Education) responsible for the validation of such learning.

The C.G. Jung Institute Zürich

The C.G. Jung Institute Zürich was founded in 1948 with the cooperation of Swiss psychiatrist Carl Gustav Jung. Jungian psychotherapy promotes the development of one’s own resources and regards a psychic problem as a challenge to individuation, an essential personal development. In practical psychotherapeutic work, the interpretation of dreams, typology, pictures, sand play, and active imagination, amongst others, are important techniques for understanding conscious and unconscious psychic processes. To become a Jungian psychoanalyst, the C.G. Jung Institute offers programs through a psychoanalysis training curriculum in Zurich and in Geneva. Three programs are offered in Zurich: one for analytical work with adults; one for analytical work with children/adolescents; and one combined training program for analytical work with adults and children/adolescents (C.G. Jung Institute Zürich, 2020a).

The C.G. Jung-Institut Zürich offers postgraduate training in psychotherapy for the title of specialist FMH in psychiatry and psychotherapy through its Antenne Romande in Geneva. It is intended for doctors in training, both FMH psychiatrists and psychotherapists and doctors of other specializations as continuing education. This postgraduate training is recognized by the Swiss Society of Psychiatry and Psychotherapy (SSPP) (Jung Institute Zürich, 2020b).

Effects of evidence-based practices on access to psychotherapy and economicity

Evidence-based medicine affects the practice of psychoanalysis through the results of clinical and extraclinical research as well as through the funding of the treatment itself. Indeed, insurance funding is based on the principle expressed in art. 2, para. 5 of the OPAS (Swiss Federal Department of Home Affairs, 1995): ‘The insurance covers the costs of psychotherapy carried out by a physician according to methods whose effectiveness has been scientifically proven.’ The same coverage should be extended to psychotherapy delivered by psychologists upon medical prescription in July 2022. Thus, research efforts to demonstrate the scientific foundations of psychoanalysis play an important role in guaranteeing access to funding for psychoanalytic treatment from mandatory health insurance. Several meta-analyses (Leichsenring & Klein, 2020; Steinert et al., 2017) provide essential benchmarks for recognizing the scientific nature of psychoanalytic treatments. In their meta-analysis, Steinert et al. (2017) compared the efficacy of psychodynamic therapy to that of other treatments with evidence-supported efficacy, particularly pharmacotherapy and CBT. This meta-analysis included 23 randomized controlled trials with 2,751 total patients. The results showed that psychodynamic psychotherapy is as effective as other treatments with established efficacy, including CBT. In a recent publication, Leichsenring and Klein (2020) examined the effectiveness of psychoanalytic therapy in treating specific psychiatric disorders. The authors concluded that several randomized controlled trials exist and provide evidence for the effectiveness of psychodynamic psychotherapy for specific mental disorders. In this book chapter, the author also concludes that ‘the perception that psychodynamic therapy lacks empirical support is not consistent with the available empirical evidence and may reflect selective dissemination of research findings’ (Shedler, 2010).

The International Psychoanalytic Association and its Research Board have made significant efforts to support psychoanalytic research. The board’s role is to make annual recommendations to the Assembly of Representatives regarding research policies, priorities, and budgets. This research support has enabled the development of many international initiatives, but we will focus on the impact that this support and international research activity have had on the evidence-based effectiveness of psychoanalysis in Switzerland. Following the convincing results regarding the effectiveness of transference-focused psychotherapy (TFP; Clarkin et al., 1999), TFP has become a reference model for treating personality disorders in both institutional and private practice. Researchers at the University Institute of Psychotherapy at the Lausanne University Hospital showed the superiority of brief psychotherapy for severe depression among hospitalized patients when added to treatment as usual, as compared to treatment as usual alone (de Roten et al., 2017). Recognizing the importance of demonstrating that psychoanalytic treatments are efficacious, the same research group is now addressing the efficacy of psychoanalysis for treating chronic depression in a large, multicenter, international project, in collaboration with local and national psychoanalytic societies. Research efforts are currently underway to move beyond measuring symptomatic outcomes and focus on outcomes specific to the psychopathology underlying the disorder’s maintenance, which are the targets of analytic treatment (see e.g., De Roten et al., 2021). Other research groups, such as in Zurich, are interested in the correlations and effects of analytic treatment on brain function (Wade-Bohleber et al., 2020).

In summary, evidence-based medicine is affecting the practice of analytic therapy by ensuring access to reimbursement from compulsory health insurance companies through scientific studies demonstrating its effectiveness. The importance of scientific evidence also promotes rich and diverse research activity on analytic therapy’s efficacy and mechanisms of action.

Follow-up on results and practice recommendations

Quality system

Even though the LAMal provides for quality control for care, few binding measures have been developed. The need to implement a quality-control system first led the Foederation Medicorum Psychiatricorum et Psychotherapeuticorum (FMPP) to commission a report from the University Institute of Psychotherapy of Lausanne University Hospital (Ambresin et al., 2015). Its conclusions after a comprehensive literature review were very general:

The current study identified a large number of quality indicators that can be used for quality assessment in outpatient psychiatry and psychotherapy. Their role is part of the overall quality process. They can help to assess the quality of the structure, the process or the outcome. Their selection is the result of an iterative process involving all interested participants at the individual level (patients and clinicians), at the department level (department head, administrators) and at the system level (professional boards, government agencies, politicians). To date, the scientific strength of quality indicators is weak. Strong recommendations are lacking for the systematic inclusion of outcome indicators in the evaluation of the quality of outpatient psychiatry and psychotherapy. Based on these findings, this report provides Swiss Society for Psychiatry and Psychotherapy (FMPP) with several recommendations for quality indicators in outpatient psychiatry and psychotherapy. The FMPP has been a leader in promoting interest in quality of care in outpatient psychiatry and psychotherapy, and in doing so is uniquely positioned to address many of the previously stated research needs in the context of outpatient psychiatry and psychotherapy in Switzerland. (p. 5)

Only recently, an amendment to the LAMal, dated 21 June 2019, was passed that strengthens the quality-control and cost-effectiveness system that will apply to care providers. With respect to psychotherapy delivered by psychiatrists, the Federation of Psychiatrists and Psychotherapists committee has been involved in a project to define the quality criteria required for psychiatrists. These comprise four main themes: supervision, participation in quality circles, therapeutic recommendations, and shared decisions with the patient. A monitoring system is foreseen by this project. This should come into effect in 2021.

Practice recommendations

In order to promote the quality of psychiatric and psychotherapeutic treatment, the SSPP develops recommendations for its members in the therapeutic field and regarding other important practical issues. These recommendations are based on current scientific knowledge and proven procedures in the field of mental health consultation. The validity of the SSPP’s recommendations is reviewed regularly. In these recommendations, one can find, for example, the document ‘Psychotherapy in Depression’ by Joachim Küchenhoff (2012), from which we have extracted the following paragraphs, which situate the places of psychotherapy and antidepressants in the treatment of the depressive episode:

In the case of a mild depressive episode, if it can be assumed that the symptoms can also be cured without active treatment, in the sense of careful observation, specific treatment of depression can be avoided in the first instance. If the symptoms persist or have worsened after a maximum of 14 days of monitoring, a decision must be made with the patient about the introduction of specific therapy.

The following recommendation is fundamental and decisive. It places great value on psychotherapy as a means of treatment. The reflex to immediately resort to an antidepressant in the case of mild to moderate depression is unambiguously resolved by this recommendation. For the treatment of mild to moderate acute depressive episodes, psychotherapy should be offered. If the depression is severe and acute, it is not appropriate to rely solely on dialogue, but also not to resort solely to drug treatment. Here too, research results are in line with clinical experience. It is best to rely on both an antidepressant and psychotherapy.

Access to psychotherapy in the health care system

Training in the three axes and the ‘paradox of equivalence’

Access to psychotherapy in the health care system is supported by the existence of the dual title of psychiatrist-psychotherapist, as seen previously, and by the reimbursement for psychotherapy by basic insurance. Three main approaches to psychotherapy are represented in institutional care settings (psychiatric hospitals and outpatient polyclinics): the family system approach, CBT approach, and psychoanalytic approach.

The atmosphere of work and collaboration between the representatives of these different approaches in Switzerland is rather calm and therefore fruitful for the patients. This is based on the tradition of Swiss federalism, in which the art of consensus and multicultural dialogue is a tradition, but also on the teaching of the three approaches in common training settings, where the ‘paradox of equivalence’ is recalled, in order to put into words the impossibility of scientifically identifying the superiority of one approach over another. Thus, it is proposed that trainees choose the approach that best corresponds to them, without any pressure from the idea that one approach to psychotherapy is superior to another. One way of presenting this choice is, for example, by evoking the ‘conversational style’ that would be specific to the participant, in order to orient their style and choice of focus. In this way, patients can access comprehensive and personalized care after considering tools and ways of understanding the difficulties that belong to these three schools. Notably, choices were made to maintain rigorous training in each of the three approaches and not integrative training, in order to privilege the existence of quality technical training in psychotherapy and to not dilute the effectiveness of these specific techniques into a ‘soft’ eclectic whole.

An example of the fruitful cooperation among psychotherapy types is an interapproach supervision group, which is used for training psychologists and medical doctors, to help them choose their approach and to show the strengths, interests, and complementarity of the clinical understandings of the three approaches, based on a clinical vignette presented by one of the participants.

Psychotherapy programs in psychiatric services

There is a tradition of psychotherapy practice within psychiatric services, particularly in French-speaking Switzerland. Notably, several large psychiatry departments have been led by psychoanalysts for years, which has allowed the development and implementation of such care offerings. We will cite some examples of these models from the Lausanne experience:

• The Model of Brief Psychodynamic Investigation (IPB) is a four-session module comprising weekly sessions over a month. IPB is delivered in Lausanne at the outpatient service for patients who spontaneously ask for an initial consultation. The IPB model allows for a psychiatric and psychotherapeutic investigation and is a brief and time-limited crisis treatment. These four consultations may be sufficient to meet the patient’s need to ‘get back on their feet,’ or they may alternatively be used to refer the patient to a longer course of treatment or psychotherapy.

• Psychotherapy for Severely Depressed Inpatient (PPDH) is a psychotherapy module lasting 12 sessions (Ambresin et al., 2009), with a high frequency of three sessions per week over 1 month, offered to depressed patients who are hospitalized in the Psychiatry Ward of Lausanne University Hospital. PPDH demonstrated efficacy in a randomized clinical trial when added to the usual hospital treatment (de Roten et al., 2017). PPDH allows the hospitalized patient to meet, during their stay, with a psychotherapist independent of the care unit, in addition to their usual care, and offers the patient an intensive individual and intimate setting.

Modern care models responding to the needs of the patients suffering the most

Recent ambitious attempts have been made to continue to offer psychiatric and psychotherapeutic care adapted to the needs of patients who suffer the most. In Lausanne, for example, patients with a personality disorder (treated by the team of Dr. S. Kolly, Service of General Psychiatry, DP-CHUV) benefit from an initial phase of psychiatric and psychotherapeutic investigation over 10 weekly sessions. This important evaluation stage, in which the particular focus is on establishing a possible working alliance with these difficult patients, opens up the possibility of a choice between three treatment options:

• a syndromic treatment, notably embodied by Gunderson’s MOC model, and which offers a good example of good psychiatric and psychotherapeutic practices being integrated for the patients suffering most.

• curative treatment, of which only psychotherapy has proven to be effective in this diagnosis. In Lausanne, treatments such as TFP (Clarkin et al., 1999) and Linehan’s Dialectical Behavioral Therapy are delivered by psychotherapists trained in these approaches through specific training programs.

• palliative treatment, using the multidisciplinary network and institutional resources, to support patients while they wait for the possibility of treatment that is more ambitious.

Integrated psychiatric and psychotherapeutic treatment (IPPT): heir to a local psychoanalytic tradition

The existence of the dual title in psychiatry-psychotherapy – and therefore of full training in psychotherapy within institutions for psychologists and medical doctors, fosters a combined understanding of the difficulties among the patients suffering most, integrating psychiatric and psychotherapeutic dimensions. Practice and training in the three approaches to psychotherapy within these institutions promotes mutual recognition of each approach’s qualities and tools as well as peaceful and quality collaboration, adapted to each patient’s needs. Diversity becomes a richness, drawing its enrichment from differences – as illustrated by the interapproach group supervision described above.

Thus, psychiatric reflection and care do not extinguish psychotherapeutic listening and vice versa, resulting in complex and quality care, leaving aside neither the external reality and the technical and sociological advances in psychiatric care nor the singularity of the patient. This has led to contemporary and ambitious interpretations and models of psychiatric care, as illustrated by various publications, including a book currently being published on contemporary psychotherapeutic approaches to psychosis (Conus & Söderström, 2021), and by the psychiatry hospital teams in Lausanne and Malévoz Hospital in Monthey using identification with the patient through psychoanalytic psychodrama as a supervision model. Updated psychoanalytical tools allow the needs of patients and caregivers to be answered in contemporary psychiatric hospitals.

Conclusion

In Switzerland, psychoanalytic psychotherapy is very much alive in health care institutions, where it is practiced and taught. The dual title in psychiatry and psychotherapy and the recent federal recognition of the psychologist-psychotherapist title support the maintenance of demanding psychotherapy training in care institutions with the patients suffering most.

Contemporary psychoanalytical psychotherapy practices have emerged, with different models: proposals for new settings for brief psychotherapy adapted to the demands of the contemporary world (IPB, PPDH); models of ‘evidence-based’ psychotherapy, requiring specific training and supervision, and responding to the most complex illnesses (TFP); and a practice of integrated psychiatric psychotherapy, offering patients a global understanding of their difficulties as well as quality responses that are best adapted to their demand for care. In parallel, outside of the institutions, but in a living link with them, notably through common training offers, local psychoanalytic societies continue to train therapists toward understanding specific models and gaining more in-depth specializations, particularly in psychoanalysis or group psychotherapy.

Ongoing research continues to support the documentation and comparison of the effectiveness of both psychoanalysis and psychoanalytic psychotherapies. This ‘action research’ is a modern and valid way of providing access to psychoanalytic treatment for patients who need it the most in the contemporary Swiss health care system.

Disclosure statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.