A evolução da psicoterapia na Europa

The Evolution of Psychotherapy in Europe

Serge Ginger

RESUMO

É uma grande honra e prazer para mim ter sido convidado a apresentar um breve panorama da evolução da psicoterapia na Europa neste 5 º Congresso Mundial de Psicoterapia na China, em outubro de 2008.
Vou começar com o resumo das cinco categorias principais (principais correntes) de Psicoterapia, em seguida, recordando algumas informações sobre a própria Europa e os seus 50 países muito diferentes, depois disso, cito o desenvolvimento das principais psicoterapias realmente praticadas na Europa: a psicanálise e as diferentes, assim chamadas de "novas terapias." Termino com a dimensão sociológica da psicoterapia e da necessidade de institutos de formação especializada.

Palavras-chave: Psicoterapia; Europa; Psicanálise; Novas terapias.

It is a great honour and pleasure for me to have been asked to present a brief overview of the Evolution of Psychotherapy in Europe at this 5th World Congress of Psychotherapy in China, in October 2008.
I shall begin with outlining the 5 main categories (mainstreams) of Psychotherapy; then, recalling some information about Europe itself and its 50 very different countries; after that, mentioning the development of the main psychotherapies actually practiced in Europe: psychoanalysis and the different so called “new therapies.” I shall conclude with the sociological dimension of psychotherapy and the need of specialized training institutes.

Keywords: Psychotherapies; Europe; Psychoanalysis; New Therapies.

Introduction

Today there exist at least 365 different methods of psychotherapy — as many as days in the year… or as many as different cheeses or wines in France! Everyone tries to introduce a new element into a classical method and re-labels the psychotherapy… to attain personal notoriety and thus become immortal! In reality, barely twenty methods are currently recognized as “scientific” and are widely practiced in Europe today, and they can be grouped into 5 mainstreams:

1. Psychoanalysis and psychodynamic approaches: according to Freud, Jung, Klein, Lacan, etc. They represent in average about 25 % of the psychotherapies practiced in Europe.

2. Cognitive-Behavioural Therapies (CBT); from 15 to 25 %, depending on the countries. EMDR desensitization can be related to this mainstream.

3. Humanistic Psychotherapies: Gestalt, Person Centered Approach, TA, Psychodrama, Body Psychotherapies, etc. They are often combined in an eclectic or integrative way and represent together between 20 to 40 % of the therapies, depending on the countries.

4. Family therapies (where the client is not a single person but the family as a whole) represent perhaps 10 to 15 % of the therapies practiced.

5. Transpersonal approaches, emphasizing the dimension of spirituality and energetic flow or trans-generational approaches represent about 5 to 10 % all together.

Europe

Before mentioning something about the development of psychotherapy in Europe, I would like to recall some basic notions about Europe itself. Europe is a small continent, but it has had a major influence on the world. It is small… but it is very complicated to understand as a whole.

For 1,000 years, it was fractured and divided by almost constant warfare between emerging countries, nations and empires. It is still ‘divided’ by numerous and completely different languages (roughly 20). Until very recently, there were two main parts: the Western democracies and the Eastern ‘block’ under the control of Soviet Union. Here psychotherapy was forbidden, except for the Pavlovian behavioural approach and some traditional hypnosis.

Since 1990, about eighteen years ago, the Soviet Empire dissolved, and all kinds of psychotherapies immediately spread all into these new liberated countries, often without any degree of control or structure.

Today, there are 50 independent countries in Europe… and some new ones appear regularly in the Balkans (South East of Europe)! Out of these 50 countries, 27 are members of the European Union, and 23 are not yet. The European Union was established initially for the free movement of labour, then as a ‘”common market”, and now tries to unify laws about education, employment, commerce, police, etc. but they do not legislate yet in two sectors of life: Defense and Health. And so, psychotherapy remains totally differentiated in each country, and, even though it is regulated by an official law in 8 countries (Austria, Italy, Germany, Netherlands, Sweden, Finland, Hungary, France), these laws are very different and the practice is unregulated in all the other countries. A law is actually in process of discussion in several countries, like United Kingdom, Switzerland, Belgium, Poland… however, none of these laws have yet been tested out in the courts, so it remains to see whether they continue to apply.

Europe can now be divided into different regions, according to the language spoken, the tradition and the culture, and the main religion practiced:The Anglo-Saxon countries collect in the West and North of Europe: United Kingdom, Ireland, Germany, the Netherlands, Austria, and, more or less the Scandinavian countries of the Northern Europe. They are mostly Protestant countries, logical pragmatists, and under a strong influence from America.

Psychoanalytical culture was developed there until the eighties and, for the last twenty years, it has been rapidly decreasing in favour of behavioural cognitive approaches — considered as more ‘scientific’ or ‘evidence-based’.

The Latin countries are largely in the South-West: France, Spain, Portugal, Italy, Romania, French speaking parts of Switzerland and Belgium. They mostly have a Catholic culture with a strong philosophical and humanistic background. They like speeches, discussion and contact. A new trend of Lacanian psychoanalysis is still developed in France with also humanistic psychotherapies, like Gestalt Therapy, TA, etc.

The Slavian countries are in the East: Russia, Poland, Ukraine, Byelorussia, Czech Republic, Slovakia, Slovenia, Serbia, Bulgaria, and the Baltic countries (Lithuania, Latvia & Estonia).

They are either Orthodox or Catholic. They are very sensitive, attracted by poetry and by transpersonal approaches. They only discovered psychotherapy since 1990, after the end of the Soviet Communistic period, and they have rapidly developed integrative and eclectics approaches, combining different western classical psychotherapies.

The Balkans constitutes a specific area in the South-East of Europe. They celebrate, or are divided by, a community of different religions: Catholic, Orthodox and Muslim and suffered many conflicts and wars over last fifteen years. They are now separated into nearly 10 countries and are opening up quickly to the psychotherapeutic movement — mostly to humanistic approaches and Family Therapy.

Psychoanalysis

It can be considered that most contemporary psychotherapies – with the notable exception of cognitive-behavioural approaches, psychodrama, family therapy and NLP – as stemming from psychoanalysis, even if they have clearly and definitively deviated from it.

As you know, the main principles of psychoanalysis are based on free verbal association allowing the expression of the unconscious; the traumas of the childhood are analyzed through the transference of unresolved conflicts on to the analyst. In the classical form, three to five sessions were given per week, over many years of analysis. Psychodynamic approaches allow for more flexibility, and even brief psychotherapy and group work.

Psychoanalysis has existed now for over a whole century and it has obviously evolved considerably, due, in one respect to changing mentalities, and secondly, to scientific research – especially in the fields of neurosciences, genetics and pharmacology.

Before reaching the age of 30, Freud opened his first office in April 1886, in Vienna, after a period of four months with Dr Charcot, in France. The first essential books of Freud, Studies on Hysteria and The Interpretation of Dreams, had little success, and the 600 copies of the second work took 8 years to be sold out! In another book, My Life and Psychoanalysis, Freud himself wrote in 1924: “During more than a decade, I didn’t have one single disciple. I remained absolutely isolated. In Vienna, I was avoided; abroad, I was unknown.”

The First International Conference of Psychoanalysis, in April 1908 in Salzburg (Germany), attracted only 42 participants: 26 Austrians, 5 Germans, 6 Swiss, 2 Hungarians, 2 English and 1 American. There was no representative from Latin, Slavic or Scandinavian countries.

At the time of Freud’s death, in 1939, there were only 24 French psychoanalysts. Since then, there has been a considerable development in France – and today there are about 5,000 psychoanalysts, spread over about thirty different organizations… which fight each other!

I give you these details about the very slow evolution of psychoanalysis in France, because this is the aspect that I know the best. It is also strange to realise that France, which took 30 years to be “converted”, is today (along with Argentina) the country in the world where psychoanalysis is the most developed, especially within many universities, and even imperialistic in outlook!

A few comments about the development of psychoanalysis in some other European countries: in Germany, Karl Abraham founded the Psychoanalytic School of Berlin in 1908, soon to be affiliated with the International Association. In fact, among the first 15 International Conferences, more than half were organized in Germany. Since a recent law on psychotherapy of 1999, psychoanalysis is one of the three methods of psychotherapy that are accepted for reimbursement by the Government.

Hungary had a major initial influence (being closed allied with Austria before 1914) with Ferenczi, Balint, Spitz, Melanie Klein, and Szondi all contributing to a major collection of books and essays.

In the United Kingdom, Ernest Jones created the Psychoanalytic Society of London in 1913. Freud was passionately fond of England. From the age of 8, he read Shakespeare in the original. The English school was affected and stimulated by the intense subsequent conflict between Melanie Klein and Anna Freud that started in 1927 and lasted almost twenty years. In 1951, there were 55 psychoanalysts in England. In 1981, the British Society included 370 members, and 40 % were not medical doctors.

In Italy, psychoanalysis was hardly developed before 1950. An Italian Society of Psychoanalysis was created in 1921, but it included only one member. In 1954, there were still only 15 members, and in 1964, 45 analysts, all of whom were medical doctors. However, fifteen years later, in 1980, one could count about 700 analysts (400 Freudians, 100 Jungians, 70 Adlerians, 100 Lacanians, 40 group analysts), which means a growth of 15 times in 15 years.

Spain is known to have been particularly resistant to the introduction of psychoanalysis, for reasons linked to Spanish cultural values, the influence of the Catholic Church and the Franco dictatorship.

The Scandinavian countries (Denmark, Norway, Sweden, Finland) have also demonstrated resistance to psychoanalysis.

In conclusion, from the beginning of the century until the end of the Second World War, for almost fifty years, psychoanalysis was practically the only psychotherapy in Europe – where it was developed especially in the Germanic and Anglo-Saxon countries. Since the 70’s and especially during the 80’s, it “exploded” in Europe, and has notably ‘conquered’ France and Italy.

Today, it seems that the approach known as “psychodynamic,” which includes different forms of psychoanalysis, individual or group therapy, has become the form of psychotherapy the most widespread in Western Europe, representing between 15 to 30 % of the psychotherapies practiced, depending on the countries. But it is slowly decreasing since the last ten years.

The “New Therapies”

After a strong development over a twenty year period since 1970, psychoanalysis seems to be showing a progressive decline in relation to cognitive behaviour therapy, family therapy and to different variants of the movement called “humanistic” or existential, containing: Gestalt Therapy (Fritz Perls), Client-centred Therapy (Carl Rogers), Transactional Analysis (Eric Berne), Psychodrama (Jacob Moreno), Psychosynthesis (Roberto Assagioli), NLPt, Ericksonian Hypnosis, and psycho-corporal or body-oriented psychotherapies.

In the past few years, transpersonal approaches (Stan Grof) and EMDR (Francine Shapiro) have also gained support, whilst ‘Vegetotherapy’ (Wilhelm Reich), Bioenergetic Analysis (Alexander Lowen) and Primal Therapy (Arthur Janov) are becoming less popular.

Client Centred Approach (CCA)

After Counseling and Psychotherapy (1942) and Client-centered Therapy (1951), the basic text by Carl Rogers, On Becoming a Person, was published in 1961, and it wasn’t until 1966 that Rogers came to Europe for the first time: first to France, then to Belgium and the Netherlands.

At this time, his concept of “non-directivity” was the most attractive and the most famous, but this concept actually created prejudice against his ideas, since the concept of non-directivity was often associated with a lax, “laisser-faire” attitude. Therefore, Rogers finally abandoned this label in exchange for “client-centred approach.” The CCA was considered revolutionary in relation to the previously existent Freudian psychoanalytic concepts and it spread rapidly, especially in educational circles as well as in the helping professions and areas of personal development. Today, its impact has become considerable in Anglo-Saxon countries where we can find around 12,000 practitioners (6,000 in Germany; 2,500 in Great Britain; 1,500 in Austria; 1,000 in Switzerland; etc.)

In Latin countries, still dominated by psychoanalysis, the Rogerian client-centred approach has developed much more slowly, and we can count barely several hundred specialists in France, Spain, Portugal and Italy. We find only 20 Associations in all the Mediterranean countries, as opposed to 84 in the Anglo-Saxon counties, where the practice of “counselling” is much more widespread. (The British Association for Counselling & Psychotherapy (BACP) includes almost 20,000 members.)

Gestalt Therapy (GT)

Conceived by Fritz Perls in 1942 (Ego, Hunger and Aggression: a revision of Freud’s theory and method, Durban, 1942), and presented in theoretical form nine years later (Gestalt Therapy, New York, 1951), Gestalt didn’t begin to truly develop until the period of the international creative movement for “liberation” of May 1968. Gestalt is emphasizing the irreducible originality of each human being; his responsibility as a unique and unified being. Gestalt Therapy proposes a holistic approach of the five main dimensions of being: physical, emotional, cognitive, social and spiritual; or if preferred — body, heart, head, others and the world (Ginger’s Pentagram, 1983). Contrary to the methods previously described (psychoanalysis & client-centered approach), Gestalt explicitly introduces the physical as well as the artistic dimensions and also the importance of the surrounding ‘field’ (environment) in which the therapy takes place. It is practiced equally well in group as in individual sessions and contemporary practitioners are interested in current research into neuroscience and the varying approaches of dynamic psychopathology (Ginger, 1987, 1995).

Gestalt Therapy developed rapidly in Western Europe since the beginning of the 70’s: in Germany, the Netherlands, Belgium, then in France, Italy and Spain. Today, the European Association for Gestalt Therapy (EAGT) interacts with around fifty training institutes in 26 European countries, including several countries of Eastern Europe, which appreciate its flexibility of adaptation to differing cultural contexts (creative adjustment).

Several countries publish scientific journals (there are more than a dozen regular publications in Europe); national and international conferences take place often, and there seem to be more innovations now in Europe than in the United States. Gestalt Therapy has now reached the third place in Europe — after psychodynamic approaches and CBT.

Transactional Analysis (TA)

Eric Berne has succeeded in popularizing Psychoanalysis by rendering it accessible to common mortals, through a lively and humoristic vocabulary, stemming from “games” and transactions of everyday life. Games People Play (1964) achieved rapidly a well-deserved success and several of its concepts reached the public sphere: the rebellious child, the normative parent, life script, parental injunctions, “win/win” attitude, as well as other terms which are widely known among therapists of neighbouring disciplines: the contract, the dramatic triangle of Karpman, re-decision, re-parenting, etc.

The TA movement was immediately highly organized with a well-structured hierarchy, which sometimes attracted criticism but which allowed it to develop with a solid foundation and to enter into new areas, such as administrative institutions and private enterprises.

In its psychotherapeutic version, TA emphasizes the importance of a clear contract, and it is an approach which integrates cognitive, emotional, behaviour and group dimensions, without neglecting the dimension of transference.

TA is practiced today in 23 countries of Europe and the European Association (EATA) includes about 6,000 members. Certification is strictly regulated and centralized at a European level, attesting to the comparable competence of therapists trained in different institutes.

Systemic Family Therapies

The movement that includes various family therapies is vast and relatively heterogeneous. I will only speak here about the systemic approach which presents several new elements and which has spread widely in Europe since the 80’s.

The unique characteristic of this method is to treat the whole family, composed of all members living under the same roof. The therapists (who often work in teams) are more interested in the games and interactions of the various members of the family, their systems of communication, rather than just the intra-psychological problems of the “designated patient” – who is often seen as only the scapegoat of a global family illness. The School of Palo Alto emphasized the damages of the ‘double-bind’ (ambiguous and contradictory messages). It recommends therapies of brief duration (10 to 20 sessions), which are often recorded on video and observed through a one-way mirror, allowing for a concerted effort of the therapeutic team. The sessions are often accompanied by assigned exercises for the family between sessions, most often separated by a month.

These family therapies have developed rapidly in several European countries (140 training institutes) and are often practiced within institutions. The European Family Therapy Association (EFTA) is represented in 31 countries and contains several thousand practitioners.

Psychodrama

Jacob-Levy Moreno created an impromptu theatre in Vienna in 1921 where he involved the audience as participants in a sort of “theatre in the round” without scenery. Two years later, a participant named Barbara, found herself transformed by the role that she had played. This was the birth of therapeutic theatre. In 1925, Moreno moved to the USA, and established the first therapeutic theatre, in Beacon, in 1936.

Psychodrama for children came to France in 1946. In 1955, the French Group for Sociometric Studies and Psychodrama, was formed under the direction of Anne Ancelin-Schützenberger (a group in which I personally participated during 7 years, since 1959). We organized the first World Conference of Psychodrama in Paris in 1964, with the participation of Jacob-Levy Moreno and his wife, Zerka. There was even their 10 years son, Jonhatan who played a role in almost all sessions!

But Psychodrama suffers from a serious handicap: it is difficult to practice in individual sessions (except through the related form of monodrama) and therefore, it is hardly used today except in institutional settings of children, or the mentally ill, or even in groups of personal development, rather than therapy.

Neuro-Linguistic Psychotherapy (NLP)

Neuro-Linguistic Programming (NLP) was developed by Grinder and Bandler, in California during the 70’s, and it was based especially upon observations of renowned psychotherapists: Fritz Perls (Gestalt therapy), Virginia Satir (family therapy), Milton Erickson (hypnotherapy). NLP is centred around meticulous models of the functioning of each person, learning efficient methods of communication and the changing of behaviour patterns, rather than the analysis of pathological behaviour – as several other therapies have done. The training to become a practitioner or ‘Master’ is rather brief (about 150 hours).

Therapeutic NLP was established recently (in 1999) and is more rigorous, involving a personal therapy, a training of 2,000 hours over 4 years, as well as extensive supervision. A European Association of NLPt has recently been created, with national associations in most countries of Western Europe.

Body-oriented psychotherapy

Deriving from the work of Pierre Janet, originally, and thus as old as psychoanalysis, it was mostly developed by Wilhelm Reich, a pupil of Freud’s. Having written his seminal work, Character Analysis, in 1933, along with The Mass Psychology of Fascism, Reich had to flee Europe to America. Later developments, in the USA and also in several European countries, have resulted in a multitude of body-psychotherapies, being welded together within the European Association of Body-Psychotherapy (EABP), with sister branches in America and South America.

Other modalities

To avoid exhausting your powers of attention, I won’t speak here today about several other methods, such as:

• Cognitive-behavioural approaches, which are taught more and more in certain universities and used in several hospitals, notably for the treatment of phobias, obsessive compulsive disorder and depression.
• EMDR (Eye Movement Desensitization and Reprocessing), which is proving very effective for PTSD (Post Traumatic Stress Disorders).
• Ericksonian hypnosis (Milton Erickson) – which works with modified states of consciousness — including a good dose of humour and paradoxical injunctions.
• Bioenergetic analysis (Alexander Lowen) that integrates the work of Reich, Lowen & Pierrakos, and emphasizes the importance of “character armour” and grounding.
• Psycho-Organic Analysis (Paul Boyesen) that combines psychoanalytical approach and body work.
• Transpersonal psychotherapies (such as Psychosynthesis (Roberto Assigioli), the holotropic breathwork of Stan Grof) that claim to surpass intra-personal and inter-personal problems, and introduce the cultural, symbolic and spiritual dimensions of the human being.

In Conclusion

I prefer to stop here with these somewhat too long and incomplete listings, to take a look at the global evolution of the situation in Europe, since the appearance of “the new therapies”, about thirty years ago.
It is clear that the dominating control of traditional psychoanalysis is diminishing regularly in all countries. It is also quite obvious that family therapies, group therapies and therapies involving the body, movement, creativity and the field (environment), not just ‘talking therapies’, are developing more and more.
These methods borrow techniques, attitudes and principles freely from each other. It is quite popular today to use interdisciplinary approaches, including technical empirical eclecticism and theoretical integration.
This also includes integration of the recent studies in the field of neurosciences, which have established a close link between psychological developments and biological phenomena (such as genetic predispositions and expression, modifications of neurotransmitters, and the creation of neuron pathways). These discoveries have informed the practice of several approaches, nourishing them and giving them a ‘scientific’ background as well.
Sociopolitical dimensions
Psychotherapy has become more and more integrated into the daily environment of the average citizen today; it is no longer reserved for the sick and the “crazy.” It exists in an intermediate zone, a crosswalk between medical, psychological and social spheres: to be in grief or mourning is not a sickness, nor is unemployment, nor is being an immigrant, being divorced, nor living with the anxiety of being accosted in a troubled section of the suburbs.
A recent French national study (CSA, National Survey, 2006) shows that 8% of the population are currently, or have been, involved with psychotherapy. It seems that in other countries, such as in Austria, this rate would be higher, almost doubled. In any case, even this minimal proportion indicates the need for a density of 50 qualified psychotherapists per 100,000 inhabitants (1,000 inhabitants means 50 to 100 persons in need of help). This would imply, for instance, about 700,000 specialized psychotherapists for China as we consider that, on average, each psychotherapist can treat about 100 clients every year, through long term or short term, individual or group psychotherapy.
As we know, at least 4 years (or more) are required for the training of a qualified professional psychotherapist. It is therefore necessary to increase the number of training institutes in most countries of Europe, America… and China.
It is important that laws exist that ensure the security of the citizens by guaranteeing a high level of specialized training and a serious commitment to professional ethics, allowing the respect for the individual, for his/her autonomy, and his/her commitments and personal beliefs, as well as professional confidentiality. But these laws should not restrict the practices of such a profession to only certain methods, or certain other professionals.
I’m very glad to say that WCP has started to award World Certificates of Psychotherapy, to the same standard as the European Certificate of Psychotherapy (ECP) and with the same requirements (3,200 hours of training over 7 years (including a relevant 1st degree) and, in the 4 years of specialised post-graduate training, including 250 hours of personal psychotherapy, theory, psychopathology, practice, supervision, deontology, etc. This opens a global quality to the practice and standards of psychotherapy, all over the world.

Referências

BERNE, E. Games People Play, Ballantine Books. 1964. (reprint 1996)

CSA (National Institute), Enqête nationale sur la psychothérapie. Paris, France. 2006.

FREUD, S. Studies on Hysteria 1895.

FREUD, S.The Interpretation of Dreams 1899.

FREUD, S. My Life and Psychoanalysis 1924

GINGER, S. La Gestalt-thérapie à l’hôpital. In HONORÉ, B. Former à l’hôpital, Toulouse,Privat. 1983.

GINGER, S. La Gestalt, une thérapie du contact. Paris, Hommes et Groupes édit. 8th edition: 2006. (translated into 6 languages).

GINGER, S. La Gestalt, l’art du contact. Bruxelles, Marabout. 9th edition, Paris, 2007. (translated into 12 languages). 1995.

PERLS, F. Ego, Hunger and Aggression: a revision of Freud’s theory and method, Durban. 1942.

PERLS, F. Gestalt Therapy, New York, Julian Press. 1951.

ROGERS, C. Counseling and Psychotherapy. 1942

ROGERS, C. Client-centered Therapy 1951.

ROGERS, C. On Becoming a Person 1961.

Endereço para correspondência
Serge Ginger
E-mail: ginger@noos.fr

Recebido em: 17/06/2011
Aprovado em: 21/06/2011