The UK has arguably been at the forefront of an evidence-based movement in mental health with the implementation in 2007 of the Improving Access to Psychological Therapies (IAPT) programme, which provided a large scale delivery in primary care of psychological therapies free at the point of access within the country’s National Health Service (NHS). Although IAPT has failed to deliver much of what it promised to do in its promise to improve outcomes for people with anxiety and depressive disorders, it has challenged the psychoanalytic and psychodynamic psychotherapy community to demonstrate the efficacy of their treatments with empirically robust evidence, so as to be included in such government funded programmes, to challenge the dominant treatment model of CBT, and to be recommended in UK national guidelines such as the National Institute of Clinical Excellence (NICE) for the treatment of specific medical and mental health conditions. Over the past decade, this journal has published many papers describing studies focussed on evidenced-based psychodynamic psychotherapies such as MBT and DIT, that have been developed in the UK and are for the most part delivered within the NHS; however, there have been fewer articles regarding psychoanalytic and psychodynamic psychotherapies that are delivered and researched within the public sector in other countries.
This special issue of the journal ‘State of the Psychoanalytic Nation’, which will be published over several volumes, seeks to address this gap by publishing papers from many different countries around the world charting the ways in which psychoanalytic psychotherapy has been developed, implemented, and researched within the public sectors of each respective nation, and how psychoanalytic practitioners locally have responded to the challenges of evidence-based practice (EBP). EBP is defined by the American Psychological Association as ‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’ (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 284). Each paper in the special issue will describe the history of how psychoanalytic psychotherapy evolved within their national health-care system; the current provision of psychological therapies, how people can access these, and the place of psychoanalytic therapy vis a vis other modalities such as CBT; the training pathways of psychoanalysts and psychoanalytic psychotherapists; and how EBP has impacted on their mental health system, including the necessity of establishing routine outcome monitoring and reporting of access, waiting times and recovery rates.
This first volume of the special issue contains papers from six countries across three continents – Canada, the US, Austria, Finland, Italy and South Africa – which together underscore the different historical, cultural and socio-political factors that have influenced the origins, advancement and contemporary status of psychoanalytic psychotherapy within each country’s health-care systems. Although psychoanalytic psychotherapy is available as a psychological treatment offered within the national health systems in all six countries, the extent of its provision varies, with Finland being the only country where psychodynamic psychotherapy is still one of the most commonly practiced psychotherapy orientations. In the public health systems of other countries such as the US and Canada, in the papers ‘Access to Psychoanalysis and Psychotherapy in the US’ by Eric Plakun, and ‘Psychodynamic Therapy in Canada in the Era of Evidence-based Practice’ by Alan Abbass and his colleagues, respectively, the availability of cognitive behavioural treatment (CBT), due to its greater evidence base, significantly outweighs that of psychoanalytic and psychodynamic psychotherapy; and in parts of Canada, the implementation of CBT has been modelled on the IAPT programme in the UK. In Austria and Italy, psychoanalytic psychotherapy additionally competes with systemic therapy within their national health systems, which in Italy is due in large part to the influence of the internationally-renowned ‘Milan School’ of systemic therapy in the 1970s and 1980s.
In all of these countries, psychoanalytic psychotherapy is mostly offered in private practice rather than in their publicly funded health services, and where it is available in the latter it is time-limited and often delivered by trainees. The gulf within the population between the rich who can afford private therapy and the poor who cannot is most evident in the US and in South Africa. In the US, psychotherapy is often not covered by health insurance which is reserved for the most part to treat mental health crises rather than longer-term psychotherapeutic interventions. In their paper ‘Psychoanalysis and Psychoanalytic Psychotherapy in the South African Context’ Yael Kadish and Cornelia Smith, describe how in South Africa, public mental health services are considerably overwhelmed and psychological services severely limited due to the continued effects of widespread poverty and intergenerational trauma resulting from the decades of institutional racial oppression, and although some psychoanalytic psychotherapists do work in the public sector, the few formally qualified psychoanalysts in the country work for the most part in private practice. Moreover, particular cultural beliefs and practices cannot be ignored in both the practice and training of psychoanalytic psychotherapists in South Africa. Much of the country’s population consult traditional healers, where healing is based on an ancestral family belief system, which needs to be understood and respected by psychotherapists so that both traditions can work together. Psychotherapists need to also be mindful of the poverty and deprivation which characterise the lives of many of the patients presenting for psychological help and how Western-oriented psychotherapy might be experienced as quite alien to their cultural or religious beliefs.
Psychoanalytic psychotherapy is, of course, the offspring of psychoanalysis and three of these articles bring to the fore the significant historical events that threatened the foundations, development and recognition of psychoanalysis in their respective country. It is fitting to start with the paper from Austria, the birthplace of Freud. In ‘Psychoanalytic Psychotherapy in Austria’, Karoline Parth, Melitta Fischer-Kern, Hemma Rössler-Schülein and Stephan Doering document the historical roots of psychoanalysis, the profound struggles it underwent during the Second World War with the prohibition of psychoanalysis during the National Socialist Regime, the exodus of Viennese training analysts, and the rehabilitation of psychoanalysis in the post-war period.
The psychoanalytic community in Italy was similarly affected by the rise of fascism and the devastating consequences of the ‘Racial Laws’ imposed between 1938 and 1943, as described in the paper ‘Psychodynamic therapy in the Public Sector in Italy: Then and Now: The Opportunity of Evidence-based Practice in the Birthplace of “Care-in-the-community”’ by Paolo Migone, who also records how the growth of the psychoanalytic tradition was subsequently impeded by the Catholic Church in Italy, which viewed psychoanalysts as threats to priests in their role in healing of the soul and disapproved of the prominence of sexuality in the theories of psychoanalysis. Psychoanalysis in Italy was also rejected on the one side by the university system which viewed it as unscientific, and on the other side by the de-institutionalisation, community and anti-psychiatry movements in the 1970s for not being sufficiently concerned with social and public health issues.
In South Africa, the laws enforcing racial segregation and oppression during the apartheid regime following the war stymied psychoanalytic training, and until the formation of the South African Psychoanalytical Association (SAPA) in 2011, psychoanalytic thinking only survived in its inclusion in universities and non-IPA accredited study groups.
The papers also reveal differences in the training of psychoanalysts and psychotherapists in the different countries, especially in those which favour psychiatrists as psychotherapists. In Italy, only medical doctors, most of whom are psychiatrists, and psychologists are allowed to train as psychotherapists, although many psychiatrists do not practice psychotherapy. Counsellors, who may come from other disciplines, are not allowed to practice in the public sector, and are seen in private practice as competitors by psychologists. The majority of the numerous psychotherapy training institutes in Italy are private institutions, but there are also a few in universities. By contrast, in Austria, psychotherapists who are neither psychologists nor psychiatrists have been legally able to train as psychotherapists since 1991, but those who are psychiatrists are favoured by the insurance providers.
Psychoanalytic psychotherapy trainings in these various countries also differ in their relationship with universities, which is interesting to compare with the UK where almost all of the clinical psychoanalytic and psychoanalytic psychotherapy trainings are not provided by universities. The situation is similar in Italy where most of the numerous psychotherapy training institutes are private institutions, with only a minority in universities. By contrast, in Finland, as detailed by Olavi Lindfors and Matti Tapio Kainanen in ‘Psychoanalytic Psychotherapy in Finland’, since 2012, basic psychotherapy training can only be provided by a university alone, or one linked with another organisation with psychotherapeutic and educational expertise. In Austria, the picture is mixed in that as well as psychoanalytic psychotherapy training being embedded in the university curricula for doctors and psychologists, during the past 15–20 years some public universities have also entered into co-operations with training societies and jointly offer master courses for psychotherapy for other health-care professions. There are also many private training institutes which offer a broad range of trainings in psychoanalytic psychotherapy, some of which have also formed collaborations with universities.
In South Africa, the situation is somewhat different in that private psychoanalytic training institutes were banned during the apartheid era, and psychoanalytic thinking was kept alive in universities. As a result, psychoanalytic training for psychologists, psychiatrists and social workers remains integrated in university and college settings and as a result, academic credibility is maintained; and many of the accredited clinical psychology internship training sites are located in public service hospitals and community clinics.
Evidence-based research and practice of psychoanalytic psychotherapy and other psychological therapies remains a challenge, however, for all of the countries represented in this volume of the journal. In Italy, despite some discussion on the implementation of evidence-based psychotherapies in the Italian NHS, there are no national rules or guidelines to date, although interest in psychotherapy research in universities is growing. In Austria there are also no specific delineated guidelines and requirements for providing evidence-based practice. In both Canada and the US, there is some evidence-based practice and collection of outcome measures including waiting times for therapies, however this is not routine in most services. In South Africa, although most psychological services provided in joint academic clinical facilities do have systems of outcome monitoring, waiting times and recovery rates, psychodynamic practitioners have struggled to produce sufficient evidence that their treatments are effective, and the authors also highlight that the conditions of real-life settings with patient populations presenting with complex needs, high co-morbidity and social problems in the country are very different from the strictly controlled criteria of an efficacy trial where the particular therapy has been tested.
The situation in Finland regarding EBP is more hopeful. In 1993, a major randomised trial, the Helsinki Psychotherapy Study (HPS) was initiated, despite some resistance at the time within the psychoanalytic and psychotherapy communities towards empirical research with its focus on randomised controlled trials, manualised therapies and the assessment of short term, rather than longer-term efficacy. This study, which has spawned numerous publications in high impact journals and received international acclaim, evaluated the effectiveness of two short-term therapies (solution-focused therapy and short-term psychodynamic psychotherapy) in comparison to two long-term therapies (long-term psychodynamic psychotherapy and psychoanalysis) in the treatment of 367 outpatients with mood or anxiety disorders recruited between 1994 and 2000 and followed up for 10 years. It has generated convincing evidence for the effectiveness of long-term psychodynamic psychotherapy in comparison to short-term therapies, gains which improved in the years after the end of therapy. The results of this study have contributed in Finland to the widespread acceptance of psychoanalytic and psychodynamic therapies as effective treatments, and their inclusion in the Finish Current Care Guidelines as recommended psychological interventions for the treatment of patients with depression, borderline personality disorder, and anxiety disorders. Outcome monitoring and reporting of access, waiting times and recovery rates of psychotherapy services are not as yet routinely collected throughout the country, but a new mental health strategy in Finland promising to improve the provision of psychotherapies in primary health care will include the requirement to collect this data.
Thus, we can see how these six countries have grappled with the demands for EBP with varying degrees of success. In spite of the many challenges encountered within both the psychoanalytic community and the external environment in each country with its unique myriad of cultural, social, political, economic and ideological characteristics, each paper sets a hopeful tone in the quest to imbed psychoanalytic and psychodynamic therapies within the panoply of evidence-based treatments available in the national health services and other public sector settings of each respective nation.