The health insurance system and psychoanalytic psychotherapy in Japan: the association with evidence-based practice

Abstract

Since 1958, the Japanese public health insurance system has covered psychoanalytic psychotherapy. Although it is called ‘standard-type psychoanalytic therapy’, it is essentially psychoanalytic psychotherapy or psychodynamic psychotherapy performed face-to-face once a week. Japan has two psychoanalytical organisations: the Japan Psychoanalytic Society (JPS) and the Japan Psychoanalytical Association (JPA), both established in 1955. Until they separated in 1980, they were one organisation that worked together to secure government approval for medical insurance coverage of psychoanalytic psychotherapy and contributed to training psychiatrists and clinical psychologists in psychoanalytic psychotherapy. Currently, less than 1% of psychiatrists and clinical psychologists in the country have undergone JPA or JPS training. Psychoanalytic psychotherapy provision nationally is difficult because psychoanalytic psychotherapists are concentrated in urban centres. Recent global trends have prompted the demand for evidence-based practice (EBP). To date, the effectiveness of psychoanalytic psychotherapy has not been demonstrated in Japan. Therefore, it is not recognised as an EBP within national measures for public mental health. However, psychoanalytic psychotherapy is essentially an ‘experience-based practice’, even though it is fundamentally different from EBP. Nevertheless, to sustain psychoanalytic psychotherapy as a viable psychotherapy in Japan, it would need to meet EBP standards.

Keywords:

• health insurance
• medical fee system
• evidence-based practice
• psychoanalytic training
• weekly psychotherapy

This special issue illustrates the ways in which psychoanalytic psychotherapy has been implemented, developed, and researched in public sectors globally, and the ways local practitioners have responded to the challenge of evidence-based practice (EBP). In this paper, I will discuss the history and current status of the Japanese health insurance system and medical coverage, training psychoanalytic practitioners, and recent trends and issues surrounding EBP in Japan.

Psychoanalytic psychotherapy in Japan’s health insurance system

Globally, health insurance systems are divided into three main categories: state-run, social, and private. In the UK, the National Health Service (NHS) – a state-owned system – is a tax-funded service, which means all the hospitals and clinics are state-run, and patients do not need to pay themselves for medical services. However, the general practitioner (GP) system clearly distinguishes the roles and functions of clinic-based GPs from those of hospital-based medical specialists and GPs provide a gateway to the latter such that the public cannot directly access specialist medical care. In Japan, Germany, and France, where social insurance systems have been adopted, most of the public is enrolled in public health insurance, and their insurance premiums provide financial resources for medical expenses. In Japan and France, universal public health insurance has been established and in Germany, universal health insurance exists in conjunction with private health insurance. In the US, which is representative of private insurance systems, public health insurance is limited to Medicare for adults aged older than 65 years and persons with disabilities, and Medicaid for low-income groups. Therefore, many citizens need to subscribe to health insurance from private insurance companies. Accordingly, in 2018, about 8.5% of the US population was uninsured.

In Japan, the public health insurance system began with the enactment of the Health Insurance Law in 1922. With the establishment of the Ministry of Health and Welfare in 1938, the former National Health Insurance Law came into effect. However, only civil servants or company employees were insured, and self-employed persons were not insured. This meant that by 1958, around 30% of the population had not enrolled in a public health insurance plan. The current National Health Insurance Act, which was enacted in 1958, came into effect in 1961; since then, all Japanese citizens have been covered by public health insurance. The Japanese public health insurance system stipulates medical fees nationwide for medical care at medical institutions, calculated at 10 yen (about 0.1 USD) per point. Patients have free access to medical institutions and can essentially receive the same standard of care nationwide. Medical fees are revised every two years after deliberation by the Central Social Insurance Medical Council, an advisory body of the Ministry of Health, Labour and Welfare (MHLW); and are then stipulated by the Minister of Health, Labour and Welfare. In recent years, medical technology outcomes and cost-effectiveness have been included in the overall evaluation of decisions regarding medical fees. Currently, patients between the ages of six and 70 years pay 30% of their medical fees for care at insurance-covered medical institutions, while the remaining 70% of their medical fees are paid by the medical fee examination and payment agency.¹

There were three kinds of ‘talking therapies’ within the specialised psychiatric therapy covered by the Ministry of Health and Welfare in 1958: ‘standard-type psychoanalytic therapy’ (50 points), ‘brief-type psychoanalytic therapy’ (20 points), and ‘psychotherapy’ (20 points). According to the psychiatric therapy guidelines presented by the Ministry of Health and Welfare in 1961, the difference between standard and brief forms was three versus two or less therapy sessions per week. More emphasis was placed on improving adaptation to real-life and interpersonal relationships in the brief form than in the standard form. Although the standard-type applied to chronic neurotic conditions while brief-type applied to less severe neurotic illness, it was possible to shift from the standard to brief form during the therapeutic process. ‘Brief-type psychoanalytic therapy’ was subsequently abolished in 1976, with ‘psychotherapy’ divided according to inpatient and outpatient services in 1988. After that, owing to the abolition or merger of medical fees, from 2008 to the present, ‘psychotherapy’ has been classified into three types: ‘inpatient psychotherapy’, ‘outpatient psychotherapy’, and ‘home psychotherapy’.

As outlined below, government recognition of medical fees for ‘standard-type psychoanalytic therapy’ within the Japanese public health insurance system was due the Medical Affairs Committee of the Japan Psychoanalytical Association (JPA). At the time, the indication and effectiveness of psychoanalytic psychotherapy in psychiatric treatment was based mainly on the subjectivity and clinical experience of a psychiatrist who was also a psychoanalyst. The current medical fee system defines ‘standard-type psychoanalytic therapy’ as a therapy that uses the free association method to analyse and interpret resistance, transference, and childhood experiences, leading to patient insight, and its main indication is defined as being for neurosis. Although medical fees for ‘standard-type psychoanalytic therapy’ have not changed since 1996, when it was increased from 350 points to 390 points, insurance providers will still pay for one session longer than 45 minutes, up to six times per month.² Moreover, physicians in non-psychiatric insurance institutions, such as the psychosomatic department, who are proficient in this therapy, can also charge for this service.

In this way, ‘standard-type psychoanalytic therapy’ within the Japanese public health insurance system is not the same as the international standard of psychoanalytic treatment which is performed four to five times a week using the couch. Instead, in Japan, psychoanalytic psychotherapy or psychodynamic psychotherapy is performed face-to-face once a week. The reason for the provision of weekly psychoanalytic psychotherapy under the name ‘standard-type psychoanalytic therapy’ in Japan’s public health insurance system is that historically, Heisaku Kosawa, the founder of current psychoanalysis in Japan,³ modified the psychoanalytic treatment he experienced in Vienna to conduct brief psychoanalytic treatment weekly in Japan.

In contrast, ‘outpatient psychotherapy’ is defined as therapy provided according to a treatment plan, where psychiatrists provide instructions and advice to patients with organic brain disorders or mental illness who are experiencing difficulties in daily life, to intervene in crises, improve interpersonal relationships and improve social adaptability. Medical fees for ‘outpatient psychotherapy’ can be charged to an examination and payment agency when performed by a psychiatrist in insurance-covered medical institutions registered as psychiatry. ‘Outpatient psychotherapy’ charges a medical fee because it is a fundamental intervention performed by a general psychiatrist in general psychiatric institutions and is essentially supportive psychotherapy and psychoeducation for psychiatric patients. To date, there has been no specified restriction regarding the duration of therapy for which medical fees can be charged under ‘standard-type psychoanalytic therapy’ and ‘outpatient psychotherapy’.

Moreover, owing to the recent influence of the medical economy and ‘evidence-based psychiatry’, for outpatient talking therapy, medical fees for ‘outpatient psychotherapy’ have increased from 360 to 400 points for sessions longer than 30 minutes and reduced from 350 to 330 points for sessions lesser than 30 minutes, since 2010. Accordingly, medical fees for a 30-minute ‘outpatient psychotherapy’ session are now higher than a 45-minute session of ‘standard-type psychoanalytic therapy’. Consequently, insurance-covered medical institutions registered as psychiatry are now likely to charge medical examination fees and payment agencies for ‘outpatient psychotherapy’ over ‘standard-type psychoanalytic therapy’.

In addition, medical fees for cognitive therapy/cognitive behavioural therapy (CBT; 420 points) charges were recognised for the first time in Japan in 2010. Initially, CBT was indicated for mood disorders such as depression; however, in 2016, obsessive-compulsive disorder, social anxiety disorder, panic disorder, and post-traumatic stress disorder were added, followed by bulimia nervosa from 2018. Medical fees for CBT were revised in 2018, which were set at 480 points for therapy sessions more than 30 minutes duration provided by medical doctors and 350 points for joint provision by medical doctors and nurses. CBT-proficient medical doctors may lodge a charge to an examination and payment agency for a total of 16 sessions when a therapy plan is created and explained to the patient. Moreover, proficient physicians may charge non-psychiatric insured institutions such as psychosomatic departments.

Psychoanalytic psychotherapy has been at the core of talking therapy in the Japanese public health insurance system since 1958. However, with the recent progress of medical technology evaluation, the focus on outpatient talking therapy in the Japanese public health insurance system has changed from conventional ‘standard-type psychoanalytic therapy’ to general ‘outpatient psychotherapy’ and specialised ‘CBT’ since 2010. If medical fees for ‘standard-type psychoanalytic therapy’ disappeared from the Japanese medical fee system, psychoanalytic psychotherapy in Japan may become a complementary and alternative therapy only available through full-fee payment by patients.

Psychoanalytic psychotherapy training in Japan

‘Psychoanalytic therapy’ has existed since the inception of the current health insurance system, and psychoanalysis has had a considerable impact on the clinical practice of Japanese psychiatrists and psychologists. In the second edition of the senior residency training manual of the Japanese Society of Psychiatry and Neurology, published in 2018, psychiatry certification consisted of practicing supportive psychotherapy, understanding CBT, psychodynamic psychotherapy, either Morita therapy or Naikan therapy, and practicing one of these therapies under supervision. Therefore, Japanese psychiatrists essentially understand psychodynamic therapy. To become a psychoanalytic psychotherapist, it is necessary to undertake further professional training through the involvement of psychoanalytic organisations after becoming a certified psychiatrist⁴ or clinical psychologist.⁵ Psychoanalytic psychotherapy is a subspecialty in psychiatry and clinical psychology in the sense that it begins after completing basic and general training as a psychiatrist or clinical psychologist.

There are two psychoanalytic organisations in Japan: the Japan Psychoanalytic Society (JPS) and the JPA. The JPS is a professional organisation that is a branch of the International Psychoanalytic Association (IPA), and the JPA is the largest academic psychoanalytic society in Japan. Initially, the JPS and the JPA were one organisation, with the JPA functioning as a domestic organisation and JPS addressing international activities. However, in 1980, the JPA split from the JPS (Okada, 2018). The JPS psychoanalytic institute offers an orthodox training course to become a psychoanalyst, based on the Eitingon model, and JPS candidates for psychoanalyst are registered as members of the JPS and IPA after completing the entire programme (Okada, 2016).⁶ Additionally, the JPS has offered a training course to become a psychoanalytic psychotherapist since 1996. However, the psychoanalytic psychotherapist training course underwent reorganisation and the JPS Allied Centre for Psychotherapists⁷ was established in 2019. Candidates seeking to become JPS psychoanalytic psychotherapists are registered as members of the centre after completing the required course. The training programme of JPS psychoanalytic psychotherapists involves delivering psychoanalytic psychotherapy under supervision, attending psychoanalytic seminars, and presenting at case conferences. The JPS psychoanalytic institute oversees all training at JPS; training analysis is required for psychoanalysts, and training psychotherapy is required for the psychoanalytic psychotherapist training course.

In contrast, the JPA permits medical residents and graduate psychology students with an interest in psychoanalysis to become members based on recommendations by two members. Some members begin training in psychoanalytic psychotherapy after joining. The JPA began its certification system in 2000, and members seeking certification need to meet certain requirements, such as performing psychoanalytic psychotherapy under supervision, attending psychoanalytic seminars, and presenting at case conferences.⁸ JPA certification needs to be renewed every five years. Since the JPA does not have a training institute, psychotherapy training is individual and self-regulated, and personal psychotherapy is not included in the certification requirements of psychoanalytic psychotherapists. However, some members of the JPA voluntarily undergo personal analysis or psychotherapy in Japan or overseas. Recently, besides the JPS, some institutes for psychoanalytic training, such as the Kyoto Institute of Psychoanalysis and Psychotherapy (KIPP), the Japanese Forum for Psychoanalytic Self Psychology (JFPSP), the Institute of Psychoanalytic Psychotherapy Osaka (IPPO) and the Support Agency for Child Psychotherapy (Sapochil), have been established by psychoanalytic therapists trained overseas. The branches of the JPS psychoanalytic institute are in Tokyo and Fukuoka, and many JPA leaders and training groups are concentrated in large cities.

Currently, the number of certified psychiatrists and clinical psychologists certified by the JPS or JPA is less than 1% of the total number of certified psychiatrists and clinical psychologists in Japan. Moreover, since they are concentrated in large cities, it is geographically difficult for many Japanese people with mental and emotional issues to access psychoanalytic psychotherapy. According to a 2015 JPA survey, 52.6% of JPA members were primarily engaged in clinical duties in insurance-covered medical institutions (20.0% in clinics, 18.4% in psychiatric hospitals, and 14.2% in general hospitals) and 37.8% in insurance-uncovered institutions (19.2% in school health facilities and 18.6% in private offices; Okada, 2017). In Japan, when it comes to the clinical practice of psychoanalytic psychotherapists, there are more people working in insurance-covered medical institutions than those not covered by insurance; thus, psychoanalytic practice in Japan is closely entwined with the health insurance system. However, given that the population of Japan in 2020 was around 125 million, it would be difficult to provide sufficient psychoanalytic psychotherapy to all Japanese people under the public health insurance system.

In addition to the JPS and JPA, another psychoanalytic organisation was established in Japan in 2003: the Japan Academic Association of Psychoanalytical Psychiatry (JAAPP). The JAAPP uses Medical Psychotherapy in the Royal College of Psychiatrists as a training model, and only doctors can become a member based on the recommendation of a member of the executive committee. As of August 2020, there were 173 members, and the certification system began in 2019.

A recent notable occurrence was the first-time recognition by the National Assembly of a national license for psychologists (the certified public psychologist) in 2015, which was separate from the 1988 establishment of the foundation for accrediting clinical psychologists. National certification examinations have been conducted since 2017. However, since certified public psychologist licenses do not presuppose graduate school completion as distinct from the training curriculum for the clinical psychologist, which does, psychoanalytical content is lacking in the certified public psychologist training curriculum. Moreover, the roles and functions of certified public psychologists are more versatile than those of clinical psychologists, and the former are not specialised in talking therapy.

Evidence-based practice and psychoanalytic psychotherapy in Japan

In the US, the directive outlined in the clinical practice guidelines published by the Institute of Medicine (IOM) in 1990 introduced an evidence-based medicine (EBM) approach to healthcare (Field & Lohr, 1990). In the UK, the NHS established the National Institute for Health and Clinical Excellence (NICE) in 1999 which publishes a variety of clinical guidelines. In Japan, the Japan Council for Quality Health Care (JCQHC), established in 1995, launched the Medical Information Network Distribution Service (MINDS) in 2002 to aid patients and medical professionals to make decisions through the distribution of high-quality clinical practice guidelines and to improve the quality of healthcare. Clinical practice guideline-based EBM is available on its website. The Japanese Central Social Insurance Medical Council aims to create a Japanese version of NICE and has been discussing medical technology and cost-effectiveness evaluation since 2012. While the establishment of NICE in the UK is primarily aimed at reducing the regional disparities in healthcare and ensuring access to cost-effective medical technology, the Japanese NICE appears to be primarily aimed at reducing the growing cost of medical care in Japan. In any case, the move towards a Japanese NICE has contributed to clinical practice guidelines by promoting ‘evidence-based psychiatry’ in Japan and has had a significant impact on the provision of talking therapy in the public health insurance system.

The clinical practice guidelines for mild depression in Japan are an example of the ways in which clinical practice guidelines affect talking therapy. The treatment algorithm for major depressive disorder published in Japan in 2003 (Motohashi & the Psychiatric Pharmacotherapy Study Group, 2003) placed both mild and moderate depression in the same category and recommended a new generation of antidepressants as a treatment option. Following this, many clinical guidelines have been published by various bodies in other countries, such as the World Federation of Societies of Biological Psychiatry (Bauer et al., 2007), the National Collaborating Centre for Mental Health (UK), 2010, and the Royal Australian & New Zealand College of Psychiatrists clinical practice guidelines team for depression (Ellis, 2004), which prioritised psychotherapy and other treatments over antidepressants as the first choice against mild depression. In 2012, the Japanese Society of Mood Disorders published the first edition of guidelines for the treatment of depression in Japan (Kanba et al., 2013) and, in 2016, published the second edition of the treatment guidelines in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. However, owing to the lack of research in a Japanese context on mild depression, clinical practice guidelines are based on a consensus between foreign guidelines and Japanese experts. The current clinical practice guidelines differentiate between mild and moderate depression, recommending supportive psychotherapy and psychoeducation as the primary interventions against mild depression. They also promote the choice of a new generation of antidepressants or CBT, or a combination of both. In addition to the interventions above, for moderate to severe depression, biological treatment such as medication is recommended; however, psychological therapies which have proved to be effective in trials outside of Japan, such as interpersonal psychotherapy, psychodynamic therapy, and problem-solving therapy are not recommended. CBT is currently the only psychotherapy in Japan for which effectiveness against depression has been demonstrated through empirical research. Overseas, a long-term empirical study of psychoanalytic psychotherapy for treatment-resistant depression has been published (Fonagy et al., 2015). However, at this time, there has been no empirical study conducted in Japan on the effectiveness of psychoanalytic psychotherapy as a treatment for depression.

As already mentioned earlier, the medical fees for CBT, which has been demonstrated to be effective against depression in Japan, were approved for the first time in Japan in 2010. Accordingly the medical fees for ‘standard-type psychoanalytic therapy’ are less than those for either ‘outpatient psychotherapy’ or CBT. Psychoanalytic psychotherapy or psychodynamic psychotherapy might not be recognised as ‘evidenced-based psychotherapy’ under Japan’s national policy. Indeed, CBT is rapidly becoming popular in the arena of Japanese mental healthcare, and psychotherapy tends to refer to CBT rather than psychoanalytic psychotherapy or psychodynamic psychotherapy.

Access to psychoanalytic psychotherapy in Japan

In the UK, the Improving Access to Psychological Therapies (IAPT; Layard & Clark, 2014) initiative, which has been in place since 2008, has influenced Japan’s national policy on talking therapies, primarily in terms of managing the quality and quantity of CBT provided to patients.

In Japan, the MHLW began a study on psychotherapy implementation methods and effectiveness from 2004–2006. Consequently, the Ministry released a CBT manual for depression in 2010, and a CBT manual for anxiety disorders in 2016. These are linked deeply to the trends of medical fees for CBT in Japan described above. In addition, the National Centre for Cognitive Behaviour Therapy and Research was established in 2011 under the National Centre of Neurology and Psychiatry (NCNP), Japan’s first training and research facility for CBT. In 2012, the Centre for the Development of Cognitive Behaviour Therapy Training (CBTT) was established to contribute to the Cognitive Behavioural Therapy Supervisor Training Project of the MHLW. These factors have contributed to the improvement in the quality and provision of CBT services and led to a Japanese version of the IAPT.

One of the key features of the commissioning and provision of psychological therapies in the NHS in the UK is outcome monitoring and reporting access, wait times, and recovery rates. In Japan, such policies are not currently implemented nationally. There may be several reasons for this. The MHLW only recognises medical fees for treatment with evidence of efficacy and recovery rate in studies carried out in Japan on Japanese populations. However, there are currently no empirical studies in Japan on the effectiveness of psychoanalytic psychotherapy with Japanese people. The Japanese public insurance system does not allow paramedical professionals to perform psychotherapies without a psychiatrist’s order. However, in reality, within insurance-covered medical institutions registered for psychiatry, it is common practice for clinical psychologists to conduct talking therapy under a psychiatrist’s order, and for psychiatrists to charge medical fees to examination and payment agencies as ‘standard-type psychoanalytic therapy’ and ‘outpatient psychotherapy.’ Regarding CBT, as mentioned above, based on empirical studies on Japanese patients, medical fees were approved for CBT in 2010, and the involvement of nurses in talking therapy was approved in Japan’s public health insurance system for the first time. However, medical fees for psychotherapy by a certified public psychologist alone are not approved at present. In the future, if a Japanese version of IAPT is promoted as a national policy, it will be necessary to further examine the possibility of medical fees for talking therapy provided by a certified public psychologist, through an evaluation of medical technology and cost-effectiveness.

In Japan there is a movement towards establishing a Japanese IAPT centred on CBT among related academic societies and local governments. Some Japanese psychoanalytic psychotherapists may anticipate that the Japanese version of IAPT will include psychoanalytic psychotherapy. Unfortunately, in Japan, unlike CBT, there is often poor management of the quality of psychoanalytic treatment, difficulty in providing adequate psychoanalytic psychotherapy by qualified psychoanalytic psychotherapists for suitable patients who can receive the therapy, and a lack of training routes and clinical practices. Furthermore, the situation does not improve access to psychotherapeutic psychotherapy, and may even make it more difficult to access psychoanalytic psychotherapy.

Toward a viable future for psychoanalytic psychotherapy in Japan

In recent years, Japan’s paradigm for talking therapy has changed from ‘experienced-based practice’ to ‘EBP’; from the individual’s perspective of the patient’s pathology and the therapist’s technique to a societal and institutional perspective of outcome and training; from one-person psychology to two-person psychology; and from psychoanalytic psychotherapy to CBT. These paradigm changes in talking therapies likely reflect the societal trend of denying the unconsciousness of the human mind and eliminating the importance of time-consuming and experience-intensive changes in psychological growth from the public mental health system. Psychoanalytic psychotherapy is currently facing a crisis of survival within Japan’s health insurance system, and the future outlook for its expansion may be limited. There is a growing trend within psychiatry and clinical psychology in Japan to eliminate psychoanalysis, driving it underground in modern psychiatry. How should psychoanalysis adapt to contemporary public mental healthcare? Moreover, what is needed to ensure a viable future for psychoanalytic psychotherapy?

The answer is probably to be found in psychoanalysis. The birth and development of psychoanalysis had a cultural background in the 19th and 20th centuries. Psychoanalysis is, in a sense, a ‘culture-based practice’; thus, it needs to adapt to the social and cultural situation of today. In recent years, in the EBP oriented health insurance system, psychoanalysis has adapted to various social and cultural demands for talking therapies. In order for psychoanalysis to survive in the future, it will need to further develop clinical practice aimed at increasing the depth and breadth of psychoanalysis.

The practice of pursuing depth in psychoanalysis is in private practice independent of the health insurance system, and it is performed by a limited number of professionals on a limited number of patients who fulfil suitability criteria using a couch and the technique of free association at a high frequency of sessions and for long-term treatment. In contrast, the practice of pursuing the breadth of psychoanalysis includes the practice of psychodynamic psychotherapy within the health insurance system, psychodynamic contributions to supportive psychotherapy and psychoeducation, and mental health in the field of employment, education, judiciary, and welfare. Psychoanalysis must also contribute to empirical research of psychoanalytic treatment and the education and training of psychoanalytic therapist. To ensure a viable future for psychoanalytic treatment, it is important to balance and interact with this depth and breadth of psychoanalytic practice.

Working towards a viable future for psychoanalytic psychotherapy among Japanese psychoanalytic organisations, the JPS is expected to pursue the nature of psychoanalysis, while the JPA, as an academic society, is expected to expand empirical research in psychoanalysis. Until now, most of the academic study within the JPA has been that of case studies. In 2015, an evidence working group was established within the JPA to gather evidence of the efficacy of psychoanalysis to ensure the future of Japanese psychoanalysis. However, at present, there are no plans for empirical studies such as randomised controlled trials on the effectiveness of psychoanalytic psychotherapy in Japan, and Japanese empirical studies of psychoanalytic psychotherapy lag behind those of CBT. In recent years, there have been many international empirical studies, both short- and long-term, on weekly psychoanalytic psychotherapy. Many of the case studies previously reported by the JPA have been about long-term weekly psychoanalytic psychotherapy, due to the influence of Japanese therapeutic culture, including the health insurance system, and the historical practice of weekly psychoanalytic psychotherapy as mentioned above (Kitayama & Takano, 2017). There is a need to rediscover the meanings and values of weekly psychoanalytic psychotherapy in Japan through empirical research in the future.

Conclusion

This paper discussed the present circumstances of Japanese psychoanalytic psychotherapy, focusing on the health insurance system, the training of psychoanalytic psychotherapists, EBP, psychotherapy access, and perspectives working towards a viable future for psychoanalytic psychotherapy. Psychoanalytic psychotherapy is one of the talking therapies aimed at reducing patient symptoms and improving their adaptability to social and mental life. In the present day, a comprehensive evaluation of evidence-based medical technology and cost-effectiveness is inevitable. However, the practice of psychoanalytic psychotherapy, which is conducted via personal interaction between the patient and the therapist, is infinitely variable. The phenomena observed in an empirical study are based on objective evaluation; whereas, psychoanalytic phenomena are always based on an intersubjective experience. Thus, modern ‘evidence-based psychiatry’ based on EBP and clinical practice guidelines may essentially differ from experience-based psychoanalytic psychotherapy; however, psychoanalytic psychotherapists need to see both the evidence and the experience.

Acknowledgements

At the time of writing, I am the editor-in-chief of the Japanese Journal of Psychoanalysis, the chair of an evidence working group in the JPA, and an executive member of the JPS and the JPA. I express my sincere gratitude to the people involved in the JPA and the JPS for training me as a psychoanalytic psychotherapist and psychoanalyst. I sincerely hope that psychoanalysis in Japan will develop further and survive in critical situation of psychoanalysis around EBP.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. There are two major medical fee examination and payment agencies in Japan. One is the Federation of National Health Insurance Association, which is primarily for self-employed persons, and the other is the Social Insurance Medical Fee Payment Fund, which is primarily for civil servants and company employees.

2. The medical fees for the first visit and the return visit in medical institutions in 2020 were 288 points for the first visit and 73 points for the return visit. For medical fees for clinical psychological examination, examination with an easy operation such as the Maudsley Personality Inventory etc. is 80 points; examination with complex operations such as the Baum test, MMPI, Rosenzweig Picture Frustration Study etc. was 280 points; and examination with complicated operation and processing, such as the Rorschach test and WAIS-III, was 450 points.

3. Heisaku Kosawa (1897–1968) returned to Japan after receiving personal analysis training from Richard F. Sterba (1898–1989) in Vienna from 1932–33 and supervision from Paul Federn (1871–1950). He established the JPA and the JPS in 1955.

4. In 2002, the Japanese Society of Psychiatry and Neurology implemented the certified psychiatrist system and began certification in 2006. Until April 2020, 11,625 individuals were registered as certified psychiatrists, with 7,911 of them serving as attending psychiatrists.

5. Clinical psychologists are certified by the Foundation of the Japanese Certification Board for Clinical Psychologists, approved by the Ministry of Education, Culture, Sports, Science and Technology in 1988; however, it is not a national licence. It is necessary to complete graduate psychology courses stipulated by the foundation and pass the certification exam. A total of 37,249 individuals were registered as clinical psychologists from the beginning of certification until April 2020.

6. As of June 2020, there were 41 psychoanalysts (38 doctors and 3 psychologists) registered as members of the JPS.

7. As of June 2020, 3 psychoanalytic psychotherapists (2 doctors and 1 psychologist) were registered with the JPS.

8. As of August 2020, 210 (117 medical doctors and 93 psychologists) out of 2,906 JPA members were JPA registered psychoanalytic psychotherapists.