The Polish network of psychoanalytic psychotherapy in the structure of the European Federation of Psychoanalytic Psychotherapy (EFPP) on the background of the actual situation of psychotherapy in Poland.
Aleksandra Pilinow, Marzena Witkowska
Psychotherapy in Poland
Psychoanalysis enjoyed a large interest in Poland before the 2nd world war. In the years following the war, psychotherapy developed around certain centres and leaders, who connected different elements of various concepts with their own clinical experience, rather than around the existing or newly forming psychotherapy schools around the world. Gradually however, groups of therapists formed, that identified with the specific theoretical approach. This was reflected in the system of psychotherapy education.
Amongst the many therapeutic approaches represented in Poland, probably the strongest position is taken up by cognitive-behavioural psychotherapy. It developed on the bases of western concepts of those like Ellis, Beck, Bandura, Meinchenbaum, Clark, but also on the Russian school of cognitive psychology and the Marxist psychology /12/. Cognitive-behavioural psychotherapy is used mainly in the treatment of depression, anxiety disorders, eating disorders, personality disorders and schizophrenic psychoses. The Polish Association of Cognitive and Behavioural Therapy exists for three years now, and since the year 2000 it is a member of the European Association of Cognitive and Behavioural Therapy. For 2 years now, Polish therapists train themselves in the first systematic training in cognitive psychotherapy, conducted by the leading representatives of this concept. One should expect that besides the classical, rationalistic and short-term cognitive approach, whose aim is to correct false cognitive schemas of the patient, the constructionistic approach will find its followers here as well /8/, /11/, /21/. It stresses the meaning of emotions as a hidden manifestation of cognitive processes and the meaning of the therapeutic relationship, understood in the light of the theory of attachment as a “safe base” for the patient, to explore himself and the surrounding reality. The main interest of the therapist is the study of cognitive schemas of the patient, which formed in the infantile or early childhood periods and following this, the formation of new interpretations together with the patient, on himself and the world. Psychotherapy in this form, described as narrative or “cognitive-developmental” /8/, is not necessarily short-termed.
Psychoanalysis and a wide spectrum of psychodynamic approaches have an ever-increasing interest amongst the therapists. Training in psychoanalysis is conducted by Polish Psychoanalytic Association, a member if the International Psychoanalytic Association (IPA), and in psychoanalytic psychotherapy it is conducted by four organisations associated in our network. Training in psychoanalytic psychotherapy is available in a few centres in Poland: Warsaw, Cracow, Lodz, Gdansk and Szczecin, however it varies in standards. Those who live and work outside these cities, can naturally enrich their knowledge and perfect their practical capabilities, but due to the local absence of psychoanalytic therapists or psychoanalysts legible to conduct training psychotherapy and supervision, they are often forced to have their own sessions with a lower frequency then that required by the EFPP, or to accumulate sessions in a given amount of time, which is followed by long intermissions. For the above-mentioned reasons, as well as economical ones, the supervisions often are in group form. At times the do not take place face to face but via e-mail or telephone contact. The training is ended with a certificate of psychoanalytic psychotherapist from the given centre. The IPA psychoanalysts have their role in the psychoanalytic psychotherapy training by conducting training psychotherapy and supervision for some of the candidates and monographic seminars. The representatives of both sides participate in the conferences organised by the IPA and the centres of the network.
The other important therapeutic concept in Poland is family and marital therapy, which arises from the systemic approach. It comprises of the integrative-communicative, strategic, structural and systemic (classical Milan family therapy, post-Milan family therapy, system-observing family therapy) /14/ approaches. Similarly as elsewhere in the world, in Poland there is a discussion on the changes in this concept, which, as in the case of cognitive-behavioural psychotherapy, have a direction towards constructionism. It means, amongst others, the change from the team behind the mirror to the reflective team present in the therapy room with the participants of the therapy, the reduction from the intervention-type of posture and expert position to a position of authenticity and reflectiveness in the therapist, interest in the language of the discussion, as one of the milieus on which a social reality is created /2/, /7/, /9/, /16/, /17/, /18/, /22/. Family therapy is represented outside the Health Service – in social aid centres, education centres and in centres for crisis intervention. The environment of family therapists is well organised. There are two sections of family therapy connected with the Polish Psychiatric Association and the Polish Psychological Association, which conduct training and propagate psychological knowledge in this field.
Certain popularity has been gained by concepts like Gestalt psychotherapy, Ericsson psychotherapy and interpersonal psychotherapy.
In the recent years research on the state of psychotherapy in Poland as compared with other European countries, has been published /4/, /5/, /6/. It can be noted that in the chosen units for psychiatric treatment, the cognitive-behavioural approach in the individual or group form is most common, and the psychodynamic approach is somewhat far behind, mostly used in the individual form. Not many centres use the systemic therapy, if they do so it is family therapy. Majority of the therapists works individually, or in teams, which most often do not have common theoretical concepts. The research shows that Polish therapists have a tendency to join in their work elements of different theoretical concepts, depending on the problem of the patient. They often use e.g. the psychodynamic concepts, even if they have not been trained in this approach. The integrative model of psychotherapy /15/ has its’ followers, however the necessity for the therapist to gain maturity and professional identity is stressed /13/, /15/. This requires a genuine readiness to work in a given therapeutic school and the gaining of many experiences.
Legal and economical aspects of using psychotherapy in Poland
Along with economical changes we have seen the emerging of a “wild market” for the use of psychotherapy. The culture of recognition and verification of the professionality of the given service is still low. The position of the psychotherapist is not yet legally affirmed in Poland, but with the beginning of the next year we will have the legalised statute of the profession of the psychologist /23/. The executive laws of this statute which describe the form of co-operation between the medical doctor and the psychologist will be the first legal regulations on the practising of psychotherapy. The statute states that the psychologist can conduct psychotherapy and the dispositions of the Minister of Health will precise the scope of this practice and its’ relation to medical treatment. In our opinion, there is a pressure from the medical environment on the subordination of the psychotherapy led by psychologists and others to the control by the medical doctors.
The qualifications of those legible to conduct psychotherapy are presently described by the centres and associations conducting courses and emitting certificates. The criteria to gain these qualifications are not uniform. The most important in the medical society, the Polish Psychiatric Association, temporarily a member of the European Association of Psychotherapy is trying to assign universal minimal conditions which have to be fulfilled by the candidates. These conditions in a certain degree are in accordance to the Strasbourg Psychotherapy Declaration signed in 1990 (1st degree medical specialisation, 3 years of work in a therapeutic centre or 5 years in another centre, 250 hours of own training therapy, theoretical training of 250 hours, 150 hours of training in the basic therapeutic skills, 60 hours of group dynamics training, 130 hours of supervision and the supervisor’s recommendation, 3 months training in a certified therapy centre). Similar standards of education of candidates applying for its licence was chosen by the Psychotherapy Section of the Polish Psychological Association. This Section is also a member of the European Association of Psychotherapy. It comprises of psychotherapists working in The Healthcare System, Social Welfare Centres, Education, Prison System and in Centres outside the Government Structures.
In the public sector existing up to now, psychotherapy was usually in stationary conditions, in comparison to other countries, where it usually takes place in outpatient conditions /6/, /20/. This is connected with the economical system. Currently, the government refunds psychotherapy in a given scope, by paying given centres for psychotherapy services or complex treatment, whose element is psychotherapy and is limiting the amount of services and treatment time that is refunded. There is no uniformity between the availability of psychotherapeutic services in different areas and no uniform criteria for the contract signing. The amount of money for a session is often very small, rather symbolic – one fifth of that in the private practice.
Two years ago, the Team of Experts of the Polish Psychiatric Association published and worked out, with some difficulty, a proposition of standards of using psychotherapy /1/, /3/, /19/. This may be a point of reference for service providers and those who pay for them. We do not have much experience with the refunding of treatment costs by private insurance companies. In many European countries it is the implications towards the patient in relation to the registered standards and qualifications of the psychotherapist to conduct the therapy that decide on the refunding of the treatment costs. In Poland, an individually practising psychotherapist has little chance of connecting his services with the public sector. In the parliament there is no lobby representing the interests of psychotherapists and their patients.
Participation of Poland in the structures of the European Federation of Psychoanalytic Psychotherapy (EFPP)
The Polish network of psychoanalytic psychotherapy is formed by four institutions of psychoanalytic orientation, who are interested in co-operating in the frames of the section for individual psychotherapy of adults EFPP: Institute of Psychoanalysis and Psychotherapy (Warsaw), Laboratory for Psychoeducation (Warsaw), Cracow School of Psychoanalytic Psychotherapy (Cracow), Centre for Psychodynamic Psychotherapy (Gdansk). We are happy for the possibility to join EFPP. We would like to be partners of other member countries in realising the statute actions of EFPP.
The participation of Poland in EFPP can considerably help in the integration of the environments conducting training in psychoanalytic psychotherapy in our country as well as offering this form of treatment. Above all a discussion is desired and the undertaking of common notions in the programme of theoretic education, as well as the means of achieving uniform standards in practical training. We count that by applying the experiences of the organisation from different member countries, we will be able to find a better solutions, than those used up to now, in the training of psychotherapists, especially in the areas far from the educational centres. Co-operation with EFPP can be also beneficial in the promotion in Poland of the knowledge of psychoanalytic theories, the psychoanalytic models of treatment and the effectiveness of their application. Psychoanalysis has in our medical environment rather negative connotations. It is often considered as a method that is out of date, based on irrational reasoning of a definitely intuitive, hence a non-scientific character, a method dangerous for the patients, who are liable to absolutely analyse and interpret the experiences from their childhood, with no connection to the present or the silence of the indifferent or lazy analyst, causing a larger discomfort of the ill. This anachronic view of psychoanalysis can be connected with a longer than twenty year absence in the continuity of its’ existence on the field of theory and clinical practice in our country. No trust towards this form of work with the patient is connected with the rather low number of actual records on its’ effectiveness and methodological problems in conducting such research. Another reason can be in the idea that psychoanalysis stands as a method in opposition to pharmacotherapy or ignores the fact that these patients are treated pharmacologically. At the same time many therapists in Poland will not take up the analysis or psychoanalytic psychotherapy, a deeply disturbed patient if she or he does not have simultaneous medical aid. What is needed, according to us, is some kind of integration of the medical and psychoanalytic models of treatment of the ill – in the private practice, as well as in the institutional treatment.
Poland is to join the European Union in the future, hence in a perspective, to adjust its’ standards of conducting psychotherapy and training of therapists in accordance to the unitary conditions. It appears that the European Association of Psychotherapy (EAP) /10/ gives a reasonable proposition in this aspect. EFPP, which is considered by this association as an organisation representing psychoanalytic psychotherapy and having a pan-European scope, could monitor the proceedings in the field of its’ own domain, recommend candidates for the European Certificate of Psychotherapist EAP. In our country there are many valued therapists, working as psychoanalytic psychotherapists who did not undergo systematic training in psychoanalytic psychotherapy, but learned their profession in a less favourable reality by fractional theoretical courses, fractional own training and most importantly, by their own practice. There are also trained therapists, whose systematic training does not abide the recent criteria of EFPP. It would appear that for some of them the application of the procedure proposed by the EAP of “grandparenting” would be useful, also in the accreditation of the European Certificate of Psychoanalytic Psychotherapist.
The Polish network has become the member of the subgroup of countries in the east and central European regions EFPP. These countries do not unfortunately have any common language base, as well as they do not have common economical and legal solutions, but this subgroup can search for common aims and ways of acting. We hope for the EFPP’s help in formulating solutions on the legal structures and procedures of functioning of the national network and its’ priorities of action.
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