Welcome to the third and final part of our special issue series entitled ‘State of the Psychoanalytic Nation’ which has charted the ways in which psychoanalytic psychotherapy has been developed, implemented, and researched within the public sectors of various nations around the world. This edition brings together accounts from Japan, India, Israel, Russia, Croatia and France. It concludes with a comprehensive overview of Psychoanalytic Psychotherapy in Europe over the last thirty years.
We begin with a paper entitled ‘The health insurance system and psychoanalytic psychotherapy in Japan: the association with evidence-based practice’ by Akiyoshi Okada. Japan, like France, uses a system of universal public health insurance. Since 1958 this has enabled access to individual psychoanalytic psychotherapy. However, influenced by NICE, Japan has been exploring medical technology and cost-effectiveness evaluation since 2012. While the establishment of NICE in the UK was primarily intended to reduce the regional disparities in healthcare and ensure equity of access to cost-effective medical treatments, Japan appears to be primarily concerned with reducing the growing cost of medical care. This has led to clinical practice guidelines promoting ‘evidence-based psychiatry’ in Japan. Due to the lack of an evidence-base for psychoanalytic psychotherapy in Japan this has had a significant impact on its provision in the public health insurance system. Psychoanalytic psychotherapy is currently facing a crisis of survival within Japan’s health insurance system, and without research evidence the future outlook for its expansion appears to be limited.
Psychoanalysis in India can be traced back to 1922, but the second paper, by Abdul Salam, Amala Shanker and Malika Verma, describes how it soon fell into decline. The authors point to a number of contributing factors, including cultural differences between European and Indian conceptualisations of relationships and the mind; the association of psychoanalysis with colonialism; and an emphasis on academia rather than clinical practice. However, the authors point to a regrowth of psychoanalytically informed clinical practice. India was one of the first developing nations to recognize the need to address mental health and launched its National Mental Health Programme in 1982. This programme was delivered at district level with the objective of providing community mental health services in primary care by training a mental health team consisting of a psychiatrist, psychologist, psychiatric social workers, and nurses in each district, along with public education to increase awareness and reduce stigma. However, the programme faced challenges integrating these services into the communities in which they functioned. Due to the very large population of India and the limited number of resources available, the major focus of intervention is still predominantly pharmacological treatments, and psychotherapy is almost completely ignored. Public hospitals and health-care systems are largely utilized by people from lower and middle socio-economic backgrounds. The delivery of these public services is often considered to be of poor quality due to inadequate resources. Moreover, psychotherapy can still be viewed as elitist, and is usually confined to the private sector – mostly in private clinics offering specialized forms of therapy including Psychoanalysis. The geographical spread is also limited, with such services being centred primarily around cosmopolitan cities. Consequently, psychotherapy services remain largely absent in rural areas and the public sector. However, the authors assert that psychoanalysis in India is neither dead nor dying. They describe pockets of practice and hope that the popularity of psychoanalytic psychotherapy will increase over the coming years, with inclusion in the National Mental Health schemes alongside other types of psychotherapy.
In the following paper, Aner Govrin, Golan Shahar and Sharon Ziv-Beiman describe the situation in Israel where psychoanalytic approaches have traditionally dominated public sector psychology and psychiatry departments. The authors describe potential challenges arising from this hegemony in both academic and clinical psychology. Since the 1980‘s the psychoanalytic modalities have engaged in dialogues with other approaches such as CBT. Clinical psychology in Israel is moving towards an evidence-based, pluralistic, and integration-oriented practice. Psychoanalytic treatments remain influential and prevalent in mental health services despite major reforms in recent years, which have allied the mental health system more closely to general health service provision. Treatment length and effectiveness evaluations have resulted in a reduction in the provision of long term dynamic therapies. However psychoanalytic treatments remain in demand in the private sector and are widely available. In academia a range of doctoral programmes offer studies in psychoanalysis and related themes and outcome research in psychoanalytic therapies is developing. Academic journals and book series address Israeli psychoanalytic themes. The authors conclude that the next two decades will be crucial in determining whether psychoanalytic approaches can maintain their position within a multi-modal landscape, or whether there will be a move towards a new hegemony.
Psychoanalysis has a long, complicated and contested history in Russia. The next paper by Constantin Lemeshko and colleagues attempts to address some of these issues, utilising the historian Ovcharenko’s ‘periodization’ model of development. They address the prevailing claim that in the ‘latent period’ after 1932, psychoanalysis was banned in the Soviet Union. The authors explain that the official philosophy of the Soviet Union in this period was dialectical materialism, within which psychoanalytic ideas are seen as a ‘false theory’. Consequently, Soviet psychiatry and academic psychology were presented with an epistemological challenge to the legitimacy of psychoanalysis. The requirement to develop an ‘objective psychoanalysis’ on a solid physiological basis led to a limited range of approaches to the methodology of psychotherapy in the Soviet Union, and a unified system of state training for psychiatrists and psychotherapists. In this system, psychoanalytic methodology has remained to this day a ‘false theory’, both in the public education system and in wider society. However, there has always remained an interest in psychoanalytic thinking amongst clinicians.
The authors describe the current situation as the ‘integrative period’, which began in 1989. During this period psychotherapy provision has increased in the Russian National Health System (RNHS). However, this is generally a brief intervention aimed at symptom reduction due to limitations in funding, and the low number of clinicians per capita of the population. The few psychoanalysts in Russia do not work within the RNHS, but some are involved in the Universities which provide clinical psychology trainings for the RNHS. The authors describe five institutions where psychoanalytic treatments are available in the RNHS. Although new Russian language treatment manuals recommend psychoanalytic treatments there is a gap in provision, and no research to provide evidence of effectiveness. The authors conclude that psychoanalytic approaches are only just coming out of latency, and face ongoing opposition within the medical institutions.
Croatia traces its psychoanalytic history back to the 1930s, when Stjepan Betlheim brought the ‘new psychoanalytic science’ to Zagreb in the Kingdom of Yugoslavia. Similarly to Russia, psychoanalytic practice entered a period of latency after the second world war. However, ideological opposition was not as strong in Croatia, and psychoanalytic practice resumed and developed. This paper in three parts, by Ivan Urlić and colleagues, describes this history in detail, as well as detailing the development of Group-Analytic practice and the provision of services for people with psychoses. Group-Analytic practice played an important role during the war in Croatia in 1991-1995 supporting refugees, displaced persons, ex-prisoners of war, and later war veterans and their family members. Four regional centres for psychotrauma were established, where modification of theory and practice was implemented to accommodate this specific presentation. Although in the public sector individual and group therapies remain in the shadow of pharmacological approaches, this may be changing as an increasing number of clinicians undertake psychodynamically oriented trainings. Two important supports for this change are the trainings in group analysis organised by IGA Zagreb and the annual meeting of Croatian ISPS network and its annual School of the Psychotherapy of Psychosis. The Covid epidemic in Croatia has also been associated with an increasing interest in psychodynamic talking therapies.
Christophe Clesse, Thomas Rabeyron and Michel Botbol describe the current situation of psychoanalysis and psychoanalytic therapies in the French health system. Although psychoanalysis no longer prevails with the extraordinary enthusiasm it inspired after World War II, it still retains an important place in the French mental health field. Psychoanalysis was the dominant modality until the mid-’90s, but has declined over the last 30 years. This paper shows how historical, cultural, and societal factors along with a strong lobby from scholars and widespread support from clinical psychology, psychoanalysis and psychoanalytic psychotherapies has maintained a significant practice framework in France. Despite a loss of momentum in the adult field, psychoanalytic psychotherapy remains essential in the provision of services for child and adolescent mental health. Academic support, a high number of clinical psychologists trained with a psychoanalytical background and the lack of regulation for therapy have all protected psychoanalysis and the psychoanalytical psychotherapy tradition in France. However, future developments to reimburse only a specific number of psychotherapy sessions might challenge the provision of psychoanalytic psychotherapy, particularly if any reimbursement policy is also associated with specific therapeutic recommendations and treatment guidelines.
We conclude this special issue series with Brian Martindale’s overview of psychoanalytic psychotherapy in Europe over the last three decades, a subject that he is uniquely positioned to discuss. In the 1980s Martindale was appointed chair of the conference committee of the Association for Psychoanalytic Psychotherapy in the NHS (APP, the organisation which publishes this journal). In 1988 he convened a European conference to explore psychoanalytic practice in other countries. Leaders in the field from Scandinavia, Germany, France etc presented to approximately 300 delegates, and Martindale recognised the possibilities for mutual learning, particularly at an organisational level. Examples included the public sector provision of psychoanalytic psychotherapy in Finland, and health economics research in Germany demonstrating the cost-effectiveness of this type of treatment. Around the same time the freedom of movement for professionals within Europe was being implemented, raising questions about the regulation of psychoanalytic psychotherapy across the EU. Consequently Martindale was appointed European Secretary of the APP. In this role he made links with colleagues from Child & Adolescent Psychotherapy and Group Analytic Psychotherapy in the EU. The work was intended to be distinct from the role of the Institute of Psychoanalysis, by focussing on applied psychoanalytic treatments in the public sector. This culminated in the foundation of the European Federation of Psychoanalytic Psychotherapy (EFPP) in 1991 of which Martindale was appointed chair.
Membership of the EFPP was via national professional networks for individual, child & adolescent and group analytic psychotherapy in the public sector. These networks were later joined by a network for couple and family work. The organisation was intended to share enough common ground to be outward looking, with a goal to share and learn from best practice across the membership.
The EFPP now offers three levels of membership – full, associate and observer, and is an umbrella organisation for 35 countries, extending beyond the original remit of EU member states. Brian Martindale is now Honorary President of the EFPP, which celebrated its thirtieth anniversary in 2021, perhaps somewhat paradoxically at a time when the United Kingdom had just left the EU. He has been instrumental in bringing this special issue series to fruition, and I am very grateful for all his help in commissioning papers from his extensive network of European colleagues.