Psychotherapy in Latvia

Interview published in the magazine Business Psychology, August-September 2008

Psychotherapy in Latvia.

Psychologist and psychotherapist Ansis Jurģis Stabingis in conversation with Līga Šaplaka How long has psychotherapy existed in Latvia? In an organized and centralized form, since the early nineties. Similar to psychology. Before that, there were individual people working in this field — for example, Jānis Zālītis worked as a hypnologist. In Lithuania, psychotherapy was much more widely developed, not to mention what was happening in Europe. Although even during Latvia’s first period of independence, there were a few followers of Freud who tried to do something. The Psychotherapists’ Association was originally called something different, but psychotherapy as we understand it today has existed in Latvia since the nineties. Just fifteen years ago, only a few directions of psychotherapy were known in Latvia, but now new ones keep appearing. How does the introduction of new directions happen? It is not quite the case that many new directions are entering Latvia. Essentially, the same few directions that already existed have been here for a long time, and only a couple have been added. Currently there are eight — Existential psychotherapy; Gestalt therapy; Family therapy; Hypnotherapy; Psycho-organic analysis; Psychoanalytic psychotherapy; Psychodynamic psychotherapy; Psychodrama. Training is also underway in Jungian analysis, which is new to Latvia, and in Analytical Vegetotherapy. There are people who have begun training in these directions. Training is also happening in individual psychotherapy methods — which are not full-fledged directions. What about the cognitive-behavioral approach? Interestingly, this direction is not represented in Latvia. Despite the fact that it is precisely this direction that is taught to psychology students at the University of Latvia, it is not represented as an independent direction of psychotherapy. There are various explanations for why this is so. We have also discussed this with colleagues. One possibility is that the direction in which each person works is chosen according to their inner philosophy. For example, when I first started reading existential works, they spoke to me deeply, were understandable and even inspiring. But when reading psychoanalytic literature, I thought — how terrible, how can one think of a person in such base terms? It is a match with my personal understanding of life — which is unique to each person, an attitude, so one can say that one direction repels a person more, while another attracts them. Now, after many years, I can delve into analytical literature and feel — yes, this is also interesting, valuable, it is great. But many years had to pass. I think that when becoming acquainted with the cognitive-behavioral approach, people who have studied psychology and gone through the study process understand that something more is needed. I recently told students at the university about some behavioral techniques, and they asked me: “And that is it? But where is the search for causes, what is the point of all this?” The answer is that the cognitive-behavioral approach is not interested in that — it is more focused on how to change behavior. Such questions are asked by students who have only just learned about it, yet it seems — they already feel that something is missing from this approach. Nevertheless, it should be noted that this is one of the most researched and scientifically validated methods, widely used in America. What is the current status of psychotherapy in Latvia? The situation is quite complex. There is no legally established regulation of what psychotherapy is — none at all. Psychotherapy as a method is currently mentioned in two places — in the list of medical specialties (which means that a physician can specialize in psychotherapy) and in the profession classifier under the section Healers. It states that healers help their clients using psychotherapy methods. Does this mean that currently anyone can call themselves a psychotherapist, and legally they have no responsibility to assume? Yes, that is how I currently understand the laws in our country. It is a legal vacuum. There are people who call themselves psychotherapists, but I do not know where or what they have studied. There are several associations in Latvia — how do they cooperate with each other? Is there any kind of hierarchy? There are several psychotherapy organizations, and the relationships between them vary. There are several psychotherapist organizations — associations in which psychotherapists representing one specific direction are united (the previously mentioned — psychodynamic, psychoanalytic, psycho-organic analysis, Gestalt, existential, family, hypnotherapy, psychodrama). These associations have united in the Latvian Association of Psychotherapists (LAP). The LAP’s core position is that psychotherapy is an independent, free profession, with its own requirements for education, knowledge, theory, methods, and so on. This profession can be acquired over four years with various foundational educations — physician, psychologist, social worker, clergyman, and others. Another core position is that various directions of psychotherapy exist that are mutually equivalent. The LAP’s activities align with the views of the European Association for Psychotherapy, which is based on the Strasbourg Declaration, which provides that psychotherapy is a free profession with various directions and various initial educations. There is also one organization whose core positions differ: it understands the word “psychotherapy” as a synonym for “psychosomatic medicine and psychodynamic psychiatry” and sees psychotherapy as an occupation accessible only to physicians. Their views also differ from the LAP on the question of psychotherapy directions — while the LAP sees them as equivalent and independent, the physician-psychotherapist association singles out the psychodynamic direction as the main one and others as methods subordinate to psychodynamic psychotherapy. In Europe, are psychotherapists also divided into physician-psychotherapists and non-physician-psychotherapists? It varies by country; one cannot say definitively that it is so. In some countries there is more division, in others less. But — for example, in the European Association for Psychotherapy (as in the LAP), it is clearly visible that people with foundational education in medicine sit peacefully and as equals at the same table alongside those with education in psychology or, say, theology, social work, and so on. Because it is possible to focus on what unites — we are all psychotherapists — or on what differentiates — you are not physicians. Looking at differences promotes division and wastes much energy that could be spent more productively. To add to the diversity, in America, for example, psychotherapy is not considered a profession but an activity performed by physicians, psychologists, social workers, clergy, and nurses. In Europe, the movement is toward psychotherapy being a profession. Can the LAP influence or track who is or is not entitled to work as a psychotherapist? Regarding the word “entitled” — as I already said, this is not regulated. The LAP is a civic organization in which people have joined voluntarily by becoming its members. No one pressured them to do it. Our influence applies only to our organization’s members. For many years we have tried writing letters to both the Saeima and the President, we have participated in several working groups at the Ministry of Health. We have tried to resolve this issue, but either we have not chosen the right methods, or for some other reason it has not happened. However, to ensure quality, we have introduced a strict quality system — certification — that complies with the European Association for Psychotherapy. We have our own code of ethics. It would be very good if legislation were in order (similar to healthcare), but currently that is not the case. Therefore it remains the case that anyone can call themselves a psychotherapist and do whatever comes to mind, and nothing will happen to them. If I as a client feel deceived, cheated, or otherwise harmed after visiting a psychotherapist, can I turn to the LAP for help? If this psychotherapist is a member of our association, then we can do something. We have our own ethics committee, code of ethics, and we can look at what happened, issue a warning, or in a more serious case, expel. But unfortunately, as an association, we cannot do anything more than that. What must one do to join the LAP? Show interest. The LAP has full members and associate members. Full members must be psychotherapists. This means they must have higher education. Second, education in psychotherapy is required, which is a separate education after obtaining higher education. Third, they must be in the association of their chosen psychotherapy direction. For example, a person with family psychotherapy education must be in the family psychotherapists’ association, and then as a member of that association they can join the LAP. On the other hand, if, for example, a cognitive-behavioral therapy specialist from America were to arrive, there is no association for this direction in Latvia, but they want to join the LAP — that is also possible. After that, one must write an application, pay the membership fee, and at the next board meeting this application will be reviewed. It should be noted that so far there has not been a case where we have not accepted someone. To become an associate member, the only requirement is interest and a written application. Associate membership is primarily oriented toward students. Are there any directions that are represented but which the LAP does not recognize, does not accept, considers not to be psychotherapy? Both yes and no. A psychotherapy direction is a complete and finished system of views on three things: • How does the person, the psyche, the personality function? • How do problems arise, why does something not work as it should? • How is it possible to fix it. All three must be present. If they are, then it can be called a psychotherapy direction. Currently in the world, by various estimates, there are about 600 psychotherapy directions, and new ones keep emerging. Some merge and some fade away over time. However, in basic orientations, there are only a few — psychodynamic, cognitive-behavioral, and humanistic. A different thing is psychotherapy methods. One such is, for example, sand therapy. It is not a direction in itself, because it has only this third aspect — how to fix problems — how by working with figurines in a sand box one can change bad things into good ones. Sand play therapy is not a direction because it does not have its own fundamental theory of how a person functions. Similarly with some other methods — which are not full-fledged directions. There are people who have learned a particular method without even being psychotherapists, and they can successfully use it in their practice — psychological counseling, treatment, or elsewhere. However, if a method does not combine all three fundamental elements mentioned, it cannot be considered a separate direction. For now, methods are not separately represented in the LAP — it is possible that over time this will change. Of course, there is discussion about whether a particular method is merely a method or can be considered a direction — that is the work of scientific evaluation. The situation in this field is not static but very dynamic — because both theories and methods are being developed, combined, and transformed. Therefore, tomorrow things may be quite different. There are also a few directions that are not sufficiently formally organized and for various reasons have not yet joined the LAP (for example, Jungian analysis), but our doors are open. Where can a client find out which directions are available in Latvia and which psychotherapists work in each direction? The LAP has a website at www.psihoterapija.lv. It contains basic information about each of the directions represented in the LAP, as well as the Latvian Psychotherapist Register — which lists all LAP-certified psychotherapists. That is how the majority of people find out about and find their psychotherapist. If a person decides to see a psychotherapist, how should they choose which direction’s representative to visit? If a person knows nothing about the directions, then they can calmly disregard that aspect, simply choose someone, and go. What matters most is how the mutual contact develops, because the direction is not that essential. (Various studies show that only about 15% of the result depends on the direction.) Another option is to read the summary of each direction on the website and then choose the one that speaks to you, that feels closest and most acceptable. What does the psychotherapists’ association give to its members? Well, it certainly provides a professional environment with colleagues, because psychotherapy is a very solitary profession. A psychotherapist meets with their client one-on-one, deeply immersed in the client’s world, personality, life — deeper, sometimes, than any other person. A psychotherapist sees about 20 such people per week and is very deeply with each person. At the same time, they cannot tell anyone anything, because confidentiality must be maintained. They live with all those secrets and experiences alone. If there are colleagues, then at least there are other people who also live with the same, work similarly, who are in a similar situation. This does not mean one can anonymously gossip about client problems, but it is important that there are people who understand what it is like. That is the collegial support — both emotional and professional. Regarding professional support — that means knowledge, discussion of various approaches and understandings. Of course, certification is also significant. What the LAP offers within the association, as well as European AP certificates. Does that mean that with this certificate I can open a private practice anywhere in Europe? Almost. However, it must be acknowledged that even in Europe, in the majority of countries, the question of psychotherapy is not regulated. The European psychotherapist certificate opens these doors wider, eases this path, but it does not mean it is automatically a green card. To say that one can unequivocally go to work in Europe with a European certificate would be an exaggeration. What else does the association give its members? We set education requirements that — through certification — provide a certain quality mark. If a person is LAP-certified, then to some extent one can say that the quality of their education meets our established standards. We also organize seminars and conferences. For example, very soon, in November, the European Association for Psychotherapy board meeting will take place in Riga. Many psychotherapists from all over Europe will be here. And from our side, we will also organize public lectures for the interested public — non-professionals — on various psychotherapeutic topics. Physicians treat with psychotherapy, but what do non-physicians do? Unfortunately, there is no such natural word in Latvian. In English, the word “treatment” is used, which has a broad meaning. In Latvian we say — providing psychotherapeutic help, which is something different from psychological counseling. It is not treatment, because not always are people ill. But sick people do come too? Yes, they do. In this case, it is a play on words. The LAP’s position is that we do not engage in treatment. That is a difference in attitude. Traditionally it is considered that a physician is in a position of power; a patient comes to them not knowing what is wrong, then the physician examines and says: clear, you have this and that, you need to do this and that. The physician knows what ails, what it is called, and how to treat it, and that is treatment. The physician is active, the patient is passive. But in psychotherapy it is different. The psychotherapist does not take this position of power. The psychotherapist does not always know what ails the person. The psychotherapist looks together with the client, explores, and together with the client finds the solution that is best for the client — or helps the client find this solution themselves. It is a completely different kind of approach, a different kind of attitude. Would it be possible for these two large orientations to eventually merge and accept each other? I would not want to agree that these are called “large orientations” — rather they are different attitudes. In a sense, this acceptance is already happening. In the Psychotherapists’ Association, in the European Association for Psychotherapy, there are quite a few physicians. Approximately a third of the members. People who, being physicians themselves, say that treatment is something completely different from psychotherapy. And, focusing on similarities, unification and acceptance are happening. However, if one focuses on differences — then unification and acceptance are almost impossible. Of course, the struggle for power also plays an essential role here — who will have the say. Unfortunately. How ready is Latvian society for psychotherapy? More and more are coming, treating it more seriously. There are also clients who, after several sessions, say that at first they came with great disbelief, but over time understood that psychotherapy is serious, it works, and it helps. How many psychotherapists are there in Latvia? In our association, there are slightly over a hundred. There could be another 50 or so who are certified but are not in the association. Approximately 100 people are in training at various levels. And about 70 more who are physician-psychotherapists. But despite this, Latvia still has considerably fewer psychotherapists than the European average. Does real demand for psychotherapists in Latvia also indicate that there could be more specialists? Yes. There are very many people who address their psychological problems with their family doctor. There are very many people who do not address their problems anywhere at all, or address them with alcohol, drugs, or the like. Therefore one can say that the real need for psychological help is great. Psychotherapy, however, is a kind of help that due to its cost is not accessible to everyone. Could insurers start covering it in the near future? Speaking of insurers — in Europe it happens that way. Inevitably it will be the same here. But there is another side — those who need psychotherapy the most are most often uninsured and still do not get access to this service. Furthermore — there is always the option of finding cheaper alternatives — even psychotherapy students or a similar type of help — psychological counseling. You just need to want it and search!