A new specter is circling Europe. The specter of the law about psychotherapy activity and education. After it was a big topic in Germany, the debate was moved to Slovenia, and now, apparently, it is also coming to Serbia. What is it about and why should it be of interest to every reader of "Vremen"? The answer is simple: every fourth person in the world needs help in conservation and improvement mental health - and in Serbia, that percentage is probably even higher - and no one wants their child to discuss the most sensitive topics with anyone. At the same time, the state (should) protect citizens from abuses and lawsuits, and wants to collect taxes, since psychotherapy is becoming an incredibly popular and lucrative profession.
Many countries do not have a law on psychotherapy (Spain, Italy, France, for example). Those that did adopt it (such as Austria, Germany, Malta, Slovenia, Croatia) did so in their own ways and with great mutual differences. It is unclear, of course, in which direction Serbia will go, whether the law will enter into force and be consistently applied, that is, when it could happen.
I reliably remember working meetings where the draft of the new Law on Psychological Activity was discussed, in the period between 2010 and 2012, and the Law has not been adopted to date. Nevertheless, here is a (non-comprehensive) overview of some European experiences, as something might prove to be applicable, if representatives of Serbian ministries and professionals really initiate discussions on this topic.
IN THE BEGINNING HARIZMA
At first, of course, there were no rules or laws. Freud appropriated the idea of the unconscious as his own discovery and personally decided who could become a psychoanalyst or, say, publish an article in journals. Everything took place in small, informal groups, since he never received a professorship due to anti-Semitism. A strange combination of factors led to the change: Freud suffered from a pronounced fear that he would die at the age of 67, psychoanalysis was spreading to faraway countries and to a larger number of people than he could personally analyze, scandals threatened to destroy the reputation of psychoanalysis... The first systematization led to a model of education that included personal analysis, at that time intensive and short, supervision and theoretical seminars, a model that, with modifications, still exists today in use it.
Although it is the beginning of the last century, everything was research and improvisation. The first university to base medical studies on the natural sciences was Harvard and it happened in 1910, and all the books on mental health care in the 19th century seem like you are reading about antiquity - leeches, baths, teas... None of the creators of psychoanalysis is a psychiatrist (although almost all of them are doctors) or a psychologist, it is simply too early for faculties and specializations as we know them. Freud himself is closest to today's neurologist, initially more of a researcher than a practitioner, with a partial education in pediatrics. In order to make psychoanalysis as influential as possible, he enrolled a musicologist (whose son would become known as "Little Hans"), an (then) important writer, and even a brilliant boy (impressed by Otto Rank's graduation thesis, Freud paid for his studies, appointed him as his personal secretary and wrote books together with him).
But laws are not written because of Otto Rank, a man so brilliant that, among other things, he invented the profession of social worker. On the one hand, they were written because the Americans needed a huge number of people to evaluate the ability to participate in the war and to treat war traumas, that is, because the Nazis practically eradicated psychoanalysis and the German state tried to support its renewal. On the other hand, they are written to protect against the worst - psychotherapists who abuse their power and exploit patients sexually, financially or politically, and unfortunately there are such people all over the world.
DEFINING PSYCHOTHERAPY
The first question that arose before the legislators was, logically, to determine what psychotherapy is. And we from the profession did not help them at all. Disillusioned psychoanalysts founded many schools, and today their number has increased to several hundred or even over a thousand. There is, of course, nothing wrong with creativity, but is it all psychotherapy and how could we check it?
The problem arose when insurance companies, on both sides of the ocean, were looking for confirmation that something really helped (if you don't believe me that they can't even mention it to pharmaceutical companies, ask Obama how his life project failed). Along with major methodological problems, empirical research into what we call the effectiveness of psychotherapy began, and it turned out that the number of forms of therapy that help people is quite small, perhaps even in the single digits. In Germany, almost half a century ago, in an extremely extensive research, it was determined that that number is three (psychoanalysis, psychoanalytic psychotherapy, cognitive-behavioral therapy) and this has not changed even with new discussions and system changes. The Swiss, of course, also recognize Jungian analysis, the British and Americans have slightly more schools, but mostly short ones (in Germany you can get three hundred free sessions), and the Austrians have reached almost thirty. In any case, it is not decided on the basis of voting, negotiation, "local products", although obviously not only on the basis of science, since otherwise the results would be much more similar.
BECOME A PSYCHOTHERAPIST
The next question was related to the education of future psychotherapists. Traditionally, it was a combination of university education and additional psychotherapy education. Freud relented in the discussion with the Americans, so until 1988, psychoanalysts there could only be doctors (that is, psychiatrists), although this did not apply to other therapeutic schools. After the famous court process between the American Psychological and Psychoanalytical Association, the training is open to psychologists, social workers, special pedagogues and nurses with doctorates. In many countries, people who have studied at other faculties are expected to complete their basic studies at one of the mentioned ones (a friend of mine graduated in social work at 59, after publishing at least ten books on the history of psychoanalysis, and my best students in Berlin were my age).
In other countries, differential exams are taken, which usually include a combination of knowledge from psychology and psychiatry (implicitly acknowledging the fundamental importance of those disciplines for psychotherapy), with an insistence on a long and supervised "internship" in institutions for mental health care.
These classes and exams take place exclusively at universities and according to accredited programs. Of the dozens of private universities where psychology is studied in Germany, only two were accepted for organizing such classes (Berlin's International Psychoanalytic University and Witten-Hardecke), and since I was involved in two accreditation cycles each in Serbia and in Germany, I am fully convinced that no private university in Serbia would pass it, and the Berlin branch of the "Sigmund Freud University" did not (at least initially) engage in it.
Exams are, of course, a prerequisite for starting work with clients and cannot be taken at the same time or after it.
Upon completion of the required level of study (or differential exams), specific psychotherapy trainings would follow. Finland is the only country where this phase takes place entirely at universities, in the USA there is a mixture, while in most countries it takes place in institutes, schools, societies - whatever you call them. Their content can differ considerably, although formal characteristics can be similar, but the most important note is their limited universality: in many countries where there is a law, after the end of the training, a state exam is taken, usually in the form of a serious knowledge test.
THE CASE OF GERMANY
The idea of psychotherapy as an independent profession in Germany was not understood the way it is now presented in Serbia (that you can become a therapist after completing part of your psychology studies), but simply and literally - there are study programs for psychotherapy that lead to the title Master of Psychotherapy.
It is important for me to emphasize that the content of these studies was not decided by psychotherapy associations or universities, but exclusively by the state (specifically, the Landesamt für Gesundheit und Soziales - something like the Provincial Secretariat for Health and Social Affairs). I attended meetings when they announced the conditions for accreditation of new programs and there was no room for negotiation. Details about those study programs can be easily found on the websites of numerous universities, but it is not difficult to summarize them: in the basic studies, it is mostly standard studying psychology with a couple of medical subjects ("Fundamentals of medicine", "Fundamentals of pharmacotherapy"); at the master's level, it is a combination of subjects from the fields of clinical psychology and psychotherapy.
This doesn't seem like a truly independent profession, but the key difference actually lies elsewhere. The novelty is not so much in lectures and exercises as in supervised practice in institutions for the protection of mental health. The programs are accredited only for the number of students corresponding to the signed contracts for such internships (as we say, with teaching bases) and if you are caught trying to enter more than one, you will lose your license. It is precisely defined what is observed or practiced at which level of study, who has the right to supervise, what kind of reports are written, how many tens or hundreds of hours each of those elements lasts, so this master's degree is much more practical than those from, say, developmental or social psychology.
You can, therefore, enroll in such a faculty (or course) at the age of eighteen and five years later have a master's degree in psychotherapy and a basic license to work, similar to the status a doctor has after completing his basic studies. It is just the ticket to real psychotherapy training, which lasts for several years to come. The story of psychotherapeutic institutes would require at least another text of this length, so I will limit myself to only two details. First, all institutes must be approved by the state and often there are rejections for professional, ethical or administrative reasons. Second, an indispensable part of the training is two internships in institutions for mental health protection, which together last about two thousand working hours. He cannot be a psychotherapist who is not able to "exist in a terrible place". And at the end of all this, comes the mentioned exam.
The peculiarity of the situation in Germany is that there are two more ways to work as a psychotherapist without being able to use that official title. The first is the "Psychotherapy Health Practitioner" license, a kind of loophole used by chiropractors, massage therapists and psychotherapists who do not belong to the above three schools and/or have not studied psychology. This license is obtained after passing one general exam and is considered less valuable, so insurance companies recognize it only in exceptional cases. (It is an old problem that the Nazis invented this category in order to force all doctors to re-register and reject the Jews and Communists among them, but it was never officially abolished later.)
Second, practically anyone can engage in so-called "unprotected professions". In Germany, you are not allowed to advertise yourself as a psychotherapist or clinical psychologist without a license, but if you write that you are engaged in psychological counseling or even psychotherapy and someone thinks that they need it, the only sanction will be an even higher tax.
WHERE PSYCHOTHERAPY LICENSES VALID
In short, everything is local. Licenses are issued by states and those outside those states are not valid. Certificates issued by psychotherapy institutes or associations may be a prerequisite for obtaining a license (in the same state), but are by no means sufficient. A certificate that said "International Psychoanalytical Association" allowed me to join a psychoanalytical institute in Berlin, but the "health authorities" were not at all interested in something issued in London or Belgrade.
When preparations for the introduction of the Bologna Declaration began in Serbia, there was talk of the European Diploma in Psychology. That was twenty years ago. There is no sign of the European diploma. There is a problem of language barriers, since in psychotherapy you have to understand the client almost perfectly. The details of the mental health care system and the legislation that governs it are never the same, to the extent that psychotherapy licenses in the US are only valid for the federal state where someone took the exam and are not valid when the patient crosses the bridge between New York and New Jersey, not to mention the fantastically developed Netherlands in this field and the still rather backward Germany. And, finally, the professions protect their interests and defend themselves against too many foreigners by asking them to repeat entire specializations, faculties, final exams or doctorates (and, if you find it unusual the attempt of some members of the Society of Psychologists of Serbia to protect their profession, imagine someone becoming a dentist, lawyer or pediatrician without completing the "basic" faculty).
CASE SERBIA
In terms of universality, the popular "European Certificate for Psychotherapy" in Serbia has no use value - you won't get a job anywhere thanks to it. In order for it to be more than good marketing, the European Commission would have to form an official institution that issues such licenses, then harmonize the legislation of all member states, then make a review in accordance with their remarks and suggestions, then evaluate which psychotherapy courses qualify, and from which countries... It sounds very nice and I would like the idea to succeed, but I am also sure that I will not experience it, if it is even possible.
Finally, we are left with the issue of the impossibility of defining and regulating online psychotherapy. As far as I know, there is still no law that applies to it, and I can't even imagine what law applies if the therapist is sitting on one continent, the client is on another, and both are traveling abroad. Can a conclusion be drawn?
Unfortunately, it seems to me that only general conclusions are possible, but not precise recommendations yet.
First, there is no rush, the law will not be in place for a very long time and the pressure is pointless. Second, everyone interested, and I mean clients and users here, should sit at the same table and do what psychotherapists usually do - listen, suggest and seek compromises. It should be released to the public in a few years, when there is some serious draft law on which everyone has expressed their opinion. Third, there are many models and one should think about which one best fits the circumstances, needs, capacities and infrastructure in Serbia. Imposing one solution as the only option neither corresponds to reality nor leads to an agreement. Fourth, there is no doubt that some people who have not completed a full degree in psychology or specialized in psychiatry understand their clients very well and have the personality traits and skills necessary to help them. Who they are and how many there are would have to be verified in an exam organized by the state, which is not an ordinary chat, and they would have to take it under the same conditions. Fifth, it is clear that no law can be applied retroactively, but the state should be asked to take responsibility for large parts of this process in the future: university education, the organization of "internships", psychotherapy in every health center and mental health care institution, granting and revoking licenses. Sixth, last, utopian, but most important: always put the integrity of the profession and the well-being of clients before personal success, earnings, promotion or influence.
The author is a psychologist
