Psychotherapy in Russia: Historical Backgrounds and Current Practice
Havenaar, Johan M., Meijler-Iljina, Ludmila, van den Bout, Jan, Melnikov, Alexander V., American Journal of Psychotherapy
Johan M. Havenaar, M.D, Ph.D.* Ludmila Meijler-ljina M.D. Ph.D** Jan van den Bout Ph.D*** Alexander V. Melnikov M.D.****
During recent years, the former Soviet states have witnessed enormous social and cultural changes, which have also greatly influenced the field of mental health, including psychotherapy. In this article, the historical backgrounds of Russian psychotherapy and its current practice are described. Psychotherapy in Russia and in Western countries share common roots, but have developed into different directions during the 70 years of Soviet regime. In more recent years, they have begun to slowly converge again. In the West, a trend away from insight-oriented, nondirective psychotherapy is taking place in favor of more directive approaches, aimed at changing overt behavior In contrast, there is a tendency for therapies in Russian-speaking countries to become gradually less directive and authoritarian. In these countries there is an increasing interest in psychodynamic, insight-oriented therapies.
INTRODUCTION During recent years, the rate of exchanges between psychotherapists in the former Soviet Union and the West has increased dramatically. Through these contacts, the influence of Western psychotherapeutic concepts on Russian psychotherapy has grown, and the knowledge about Russian psychotherapeutic concepts and methods has become more accessible to the West. Until recently, information about psychotherapeutic theory and practice in the former Soviet Union was scarce. Granted, a number of leading exponents of Russian psychophysiology and psychology, like Pavlov, Vigotsky, and Luria, have gained worldwide recognition because of their contributions in the fields of neuroscience, but it is still generally assumed that psychotherapy in Russia is practically nonexistent. This assumption is, however, to a large extent based on prejudice and incorrect. The use of psychotherapy and related techniques is much more common in the countries of the former Soviet Union than is generally acknowledged. Although the number of psychotherapists is very low in comparison to most countries in North America and Western Europe, psychotherapy is practiced in a number of settings in mental health care and in psychosomatic medicine in Russia. The concept of psychotherapy is used in a wider definition in Russia than is usually the case in Western countries. It includes all healing methods that make use of information and emotion. As such, it is an integral part of medical practice in general. Psychotherapy plays an especially important role in preventive medicine and is practiced for this reason in "sanatoria" and "prophylactoria," which exist in all parts of the country, often in resortlike settings. Another important field in which psychotherapy is practiced is in the treatment of (psycho-) somatic disorders.
In Russia the profession of "psychotherapist" has only been officially recognized since the late seventies. Specialization courses for psychotherapy, lasting three to six months, require a previous experience of two years in psychiatry. During this period the trainee usually works in a clinical ward with neurotic patients. In addition to these psychiatrist-psychotherapists, there is a small but increasing number of psychologists who practice psychotherapy, often however without having followed specialized courses after their basic university training in psychology.
Most psychiatrists and psychotherapists in Russia are more or less familiar with the main Western psychotherapeutic schools, even though usually the practical experience in the application of these therapies is lacking. The developments in this field in Russia, to a large extent, took their own course. Partly, this was because of the long-standing ideological isolation, which was unfavorable toward Western-style psychotherapy. Also, the closely knit structure of Soviet society put different demands upon the mental health care system. The main criticism of Western psychotherapies was that their main emphasis was on the intrapsychic aspects of psychopathology and little attention was paid to social factors.
In this article, an overview is given of the historical background of psychotherapy in Russia. The main forms of Russian psychotherapy are discussed and a description will be given of the current situation of psychotherapy in the former Soviet Union, especially the situation in the European republics. The article is based on the personal experience of the authors, a number of classical Russian texts,1-4 and on a review of the available English-language literature.5-7 The first and third author, respectively a psychiatrist and a psychologist from the Netherlands, have visited the Russian Federation, Belarus, and Ukraine frequently, and gave workshops and seminars on psychotherapy for psychiatrists, psychologists, and social workers. The second author was born in the Republic of Belarus. She worked for many years as a psychiatrist in the Byelorussian capital of Minsk, and now works in the Netherlands. The fourth author is a practicing psychotherapist in Moscow today. With this article we hope to make a contribution toward a better understanding of the theory and practice of past and present psychotherapy in Russia.
In our account, the history of psychotherapy in Russia will be divided into three periods, each characterized by a different political climate and, accordingly, by different relationships with the Western world.
BEFORE THE REVOLUTION
The introduction of the concept of psychotherapy and its first practice in Russia is attributed to A. Tokarsky, who in 1890 wrote a book entitled The Therapeutic Use of Hypnotism.4 Tokarski taught hypnotherapy at the Moscow University. His work was continued by V Bechterev (1857-1927). Bechterev studied with Charcot in France and Dubois in Switzerland. Early in this century, after he returned to Russia, he started conducting group sessions for alcoholics. Bechterev also introduced "rational therapy" in Russia, which was based on the work of his teacher Dubois. Dubois,8 whose work was translated into Russian in 1912, considered irrational thoughts one of the primary causes of neuroses. Rational therapy consisted in principle of convincing the patient to return to the path of reason by talking to him.
Another pioneer in the field of psychotherapy, whose work would profoundly influence psychotherapy inside and outside of Russia, was Sechenov, a physiologist who in 1863 was the first to formulate the paradigm of the conditioned reflexes of the brain. In later years, the work of Sechenov was given a scientific foundation and made famous by Pavlov (1849-1936), who conducted his well-known experiments with "conditioned reflexes" in dogs. Pavlov9 believed that the conditioned reflex was the basis for a number of mental states and conditions. For example, he saw the hypnotic trance as a condition of cortical inhibition.5 The work of Pavlov was one of the important sources of inspiration for the American psychologist Watson, who introduced behaviorism. Although Pavlov's work has certainly influenced the field of psychiatry in Russia, its influence on psychotherapy was limited.
Another important pioneer from this early period in Russia, Vigotsky (1896-1934), was opposed to the reflex theory of Sechenov and Pavlov, which he considered too mechanistic. He propagated the study of the human mind as an independent phenomenon that should be investigated independently of its physiological substrate.10 The content of individual mental processes is determined a great deal by the language a person speaks. Vigotsky based his work to a large extent on the early work of Piaget on the development of cognitive functions in children. When a child learns a language, it internalizes at the same time the relationship between things and people, according to schemata, as they are generally accepted by the people around it. Vigotsky, therefore, maintained that the individual psyche can only be understood from its social and historical perspective, and for this reason he rejected introspection as a means to gather knowledge about mental processes. Although Vigotsky's work fell from grace in the Stalin period, his heritage influenced the ideal self-image of the socialist man, as it developed in the Soviet Union. In this way the ideas of Vigotsky, even though he was not a psychotherapist himself, formed an important basis for Russian psychological theory and practice.
Apart from these Russian scientists, the main founders of psychotherapy in Western Europe and, particularly, the work of Freud exerted their influence on Russian psychology, especially in the period before the revolution.
FROM 1917 TO THE MID-SEVENTIES
The revolution of 1917 resulted in a total change of the social and scientific life in Russia. The authoritarian state was increasingly taking control of every aspect of daily life, and also affected the relationship between doctor and patient. This certainly was the case in psychiatry, which eventually became one of the instruments of power in the totalitarian state. To a much lesser extent and in a far more subtle, symbolic way, the authoritarian social structure also influenced disciplines related to psychiatry, such as psychotherapy.
The history of psychotherapy in Russia after the revolution may be broadly divided into two periods. The first period, which lasted until the mid-seventies, may be called "the period of seclusion." In this period, Western psychological theories, such as psychoanalysis and existential humanistic psychology, were sharply criticized and repressed. Western psychotherapeutic schools were being studied less and less, and their methods were no longer applied. Important branches of psychology, such as psychometrics and social psychology, were ostracized for being "reactionary" or "showing little promise." Pavlov's theory of the reflexes was upheld as the only true dialectical materialistic psychology and it remained the leading theory for a long time. The works of Freud and the psychoanalytic society had been forbidden since 1933, but as so often in Russia, official criticism did not mean that Western psychotherapies were totally forgotten. Books were illegally copied and distributed.
At the same time, the isolated position of Russia, and the idealistic zeal that characterized the first decades after the revolution, stimulated a search for new methods, also in the field of psychotherapy. The work of earlier Russian psychotherapists was continued, and to a lesser extent the methods of foreign authors, such as Dubois,8 Schultz,ll and Frankl,12 were applied in psychotherapy. The two leading psychotherapeutic directions in this period were rational therapy and suggestive psychotherapy
Rational therapy, which was based on the principles formulated by Dubois, is still one of the most popular forms of psychotherapy in Russia today. It is used both in individual and group therapy. Usually treatment with rational therapy consists of a brief, once-weekly course of about 10 to 20 sessions, lasting approximately one hour. Therapy can take place in individual and group settings and often makes use of lectures, discussions, movies, etc. The approach is directive and uses techniques, such as convincing, explaining, encouraging, distracting, etc. The essence of the method is to create in the patients the right attitude toward their illness, by promoting their understanding and insight into its background, with a strong emphasis on the social significance of the patient's behavior. The treatment sessions usually proceed according to a general structure in which the following phases may be discerned:
A relaxation phase, in which the patient is relaxed, sometimes with the use of tranquillizers or hypnosis;
An explanatory phase, in which the patient is encouraged to be aware of the connection between his symptoms, on the one hand, and life events, personality traits, and conflicts, on the other. The therapist helps the patient to trace internal contradictions and illogical thoughts and tries to replace these by more rational ideas;
A reconstruction phase, in which new behavioral patterns are developed, practiced, and reinforced
Both practically and theoretically, rational therapy shows a resemblance to the Rational Emotive Therapy of Ellis14,15 and to Beck's Cognitive Therapy for Depression.l6 This is not surprising, considering their common origin in the work of Dubois.8 There are, however, some important differences, e.g. the fact that there is no emphasis on the relationship between thoughts and feelings in the Russian variant.
A second important direction, suggestive treatment, is the most widely used method at the current time. The suggestive approach is used in a number of variations: hypnotic trance, suggestion in waking condition, suggestion under the influence of tranquillizers (narco-psychotherapy) and auto-suggestion.17 Sometimes suggestive machinery is used, e.g., an "electrical sleeping machine," that supplies low-voltage electricity through electrodes to the temples of the patient, who is recumbent on a couch. Alternatively, the electrodes are connected to the skin above the eyes, and sometimes at the same time a low dose of tranquillizers is applied through the conducting-gel. In this manner a very relaxing and healing sleep is induced in the patients. Some institutes have a specially decorated hypnotherapy room with, for example, hundreds of small lights glimmering in semi-darkness. In such a room the patients can lie down and listen to music and the voice of the therapist through earphones connected to an intercom system. Usually direct suggestions are given, for example, "I can cross the streets" or "I feel better every day."1
EMOTIONAL STRESS THERAPY
Some authors recognize a special variant of therapy which is called emotional stress therapy.4 This therapy is usually practiced as an adjuvant to other treatment forms, e.g., to group therapy. The emotional stress therapy precedes the other therapy and consists of bringing the patient into an emotional and physiological arousal state in order to enhance suggestibility. This state of arousal can be induced in several ways, e.g., with the use of intermittent warm and cold baths or by the application of fragrances to the bathwater.
THE PERIOD AFTER 1975
Since the mid-seventies, Russia gradually became more accessible to the West and its theories. Literature about foreign theories of personality and psychotherapy became more available. Although the official position towards the West was still highly critical, a number of new psychotherapeutic techniques were introduced and the use of psychotherapy increased. During this period, psychotherapy chairs were set up in the main centers, with VE. Rozhnov as professor of psychotherapy at the "Central Institute for Advanced Medical Training" in Moscow, and B.D. Karvassarsky as professor at the "Bekhterev Institute of Psychiatry and Neurology" in Leningrad (now St.Petersburg). The textbooks, on which this review is based, largely originated during this period, and articles on the subject started to appear in the only Russian psychiatric journal, Korsakov's Journal of Neuropathology and Psychiatry, named after the famous neurologist. Within the ministry of health a "Center for Psychotherapy"was founded, of whom Rozhnov became the chief.
In the first place, more psychodynamically oriented therapies were developed, in which intrapsychic or interpersonal dynamics were given attention. Also, just like in many Western countries at that time, there was an increasing interest in the use of nonverbal methods, such as creative therapy and psychodrama.
This is an example of an explorative psychotherapy that was introduced toward the end of the seventies.2 In this form of psychotherapy, fully in agreement with the principle of dialectical materialism, the relation between human beings and their environment was central. A key concept in pathogenetic psychotherapy is the concept of "otnoshenia," which literally means "relation". This term does not only apply to the relation between persons but also to the relation between an individual and his/her environment in general, for example, to his work or to material things. In this sense the word has more the meaning of "attitude." The concept of otnoshenia clearly shows the influence of Vigotsky (the internalized relationships). In pathogenetic psychotherapy the therapist aims to uncover disturbances in the system of the otnoshenia and to restore the balance in this system. Disturbances in otnoshenia can occur when there are conflicts between personality and specific life circumstances. Personality in this context is conceptualized as a system of interactions between individuals and their environment. A conflict can arise between persons, or between demands and a person's ability to meet those demands. Also, a conflict may arise from internal contradictions in the person's outlook on life. When such internal contradictions within otnoshenia cannot be resolved, neurosis develops. There are several types of neuroses which differ according to the type of underlying conflict. For example, the hysterical neurosis is usually thought to arise from a conflict between desire and reality.
Although these theories about the pathogenesis of mental suffering resemble the traditional Freudian neurosis concept to a large extent, they differ from it in that they do not attribute a role to the unconsciousness. Also desires are not being reduced to the primal drives, such as sex and aggression, but instead real conflicts in the present life of the patient are emphasized. The main resemblance between psychogenetic psychotherapy and Western psychodynamic therapies is the fact that in both cases insight is the most important method to promote change. Also, they show resemblance to the "schema focussed approach" in cognitive psychotherapy, e.g., for treating personality disorders.18 In this variant of cognitive psychotherapy, personality disorders are perceived as consisting of maladaptive cognitive schemata that shape a person's perception of the world and his/her ensuing actions and reactions.
Since the mid-seventies a number of more or less dynamically oriented forms of group and family therapy were introduced as well.l9 Although working with groups has been practiced since the beginning of the century, and working with the parents was common in child and adolescent psychiatry, these group and family sessions usually had a mainly educative purpose. No attention was given to group dynamic processes, nor were these processes used as a therapeutical aid. In the late seventies and eighties, however, several forms of dynamic group therapies emerged. In, for example, the emotional stress group therapy, the interaction between group members is used to achieve a state of emotional arousal in order to enhance suggestibility. During the group sessions, a number of techniques may be used, for example, role playing, psychogymnastics (the expression of emotion with the help of mime or pantomime) or projective drawing (drawing as a means of expressing emotions, which may be subsequently discussed in the group). Also, the role of the therapist gradually became more flexible. However, even though the therapists could now also use other therapeutic stances, such as the partner principle or abstinence from active intervention, the directive approach remained dominant. The course of the group sessions was still largely being determined by the therapist, for example by his introduction of assignments or themes for discussion. This is called "structuring the session, with the possibility of improvisation."2
SIMILARITIES AND DIFFERENCES
Although, as may be clear from the above, the psychotherapeutic practice in Russia shows many similarities with that of the West, there are a number of important differences: An important difference is the principle of the clinical approach, which refers to the fact that psychotherapy in Russia always takes place within a medical model. This means that the condition of the patient before, during, and after psychotherapy is judged primarily from a clinical point of view, i.e., whether the psychiatric syndrome is still present or not. In the West, psychotherapists tend to work with diagnostic formulations derived from psychotherapeutic frames of reference rather than with psychiatric diagnoses. Interestingly, the introduction of standardized classification systems in psychiatry, such as DSM-IV and ICD-10, has a tendency to induce a more clinical, diagnosis oriented approach in the West as well.
The focus of the therapy is mostly on the individual patient. In many Western countries, during group therapy or family therapy, the sessions are conducted not so much at the level of the individual patient but rather on the level of the group or (family-) system. The individual problems of the patient are "subordinated" and much attention is focused on the interactions taking place during therapy. In contrast, Russian therapists focus mainly on the individual. This brings to light an important discrepancy between the theory of Russian psychotherapy, which emphasizes strongly the importance of social relations, and its practice, which does not.
Russian psychotherapy is not very process-oriented. Most psychotherapy is educational or pedagogic in nature, and depends very much on the authority of the therapist. Concepts, such as "clarification," "influencing," or "learning" describe the therapeutic process better than concepts, such as "growth," "working through" or "transference".
One of the largest differences, which struck the Western authors of this article again and again during the seminars when psychotherapy was role-played, was the fact that Western psychotherapists take it for granted that there is some form of mutual trust between the therapist and the client. The doctor-patient relationship in Russia is traditionally characterized by somewhat more caution from the side of the patient. Related to this issue is our observation that the Russian therapist will be somewhat less restrained in expressing a moral opinion about the patient. They will more readily try to convince patients of the consequences of their behavior for the relation with their environment by, for example, asking: "which man would like to marry a woman who behaves like you do?"
This does not imply, however, that understanding, sympathy and support were (and are) any less important in Russia in psychotherapy than they are in the West. Perhaps the difference in doctor-patient relationship was one of the reasons why "open" forms of treatment, such as psychodynamic group therapy or psychoanalytic therapy, which demand a great deal of openness from the side of the patient, had much less chance to develop. It seems self-evident that the basic definition of the doctor-patient relationship was strongly correlated to the totalitarian structure of Soviet society. During the seminars, which the first and the third author held in Russia about cognitive psychotherapy, sometimes the question was raised: "How can you know that the patient is telling you the truth?" For Westerners it is sometimes difficult to imagine how deep the totalitarian state has left its traces in the psyche of practically every Russian citizen. In Soviet Russia, the psychiatrist/psychotherapist-patient confidentiality was not always safeguarded and one could not risk to disclose one's deepest thoughts or feelings. During the Soviet era most people depended on their close ties with friends and relatives to share their everyday problems. This may have been an other reason why the demand for psychotherapy was smaller than in more individualistic Western societies. Conversely, the probing question of our Russian workshop participants also confronted us with the fact that Western psychotherapists may sometimes take the all-confiding and truthful nature of the therapeutic relation too much for granted. Most psychotherapists probably have the experience of treatment failure, e.g., with cases of covert substance abuse, that can testify to this.
THE CURRENT SITUATION
Currently interest in psychotherapy in Russia is rapidly increasing, causing a booming of the field. Since 1990, more than ten new psychotherapy departments at medical institutes have been established in different parts of Russia and other new independent states. Several new scientific societies and journals have been created. A wide range of psychotherapeutic methods is applied, including a Russian version of psychoanalysis, which combines psychoanalytic ideas with suggestive techniques.
Also, slowly but certainly, psychologists who are working in psychiatry, are leaving their research laboratories and start to conduct psychotherapy. Most of them are eager to practice psychotherapy, but so far a legal basis for their practice is lacking (they are supposed to be just assistants of doctors). In comparison with psychiatrists, they are often more familiar with the English language and with Western psychotherapeutic approaches, and tend to be more active in their pursuit of new developments. Just as in many Western countries, there is an element of cooperation as well as strife between psychiatrists and psychologists. Slowly new disciplines, such as social work, are also entering the field. In a number of the larger cities, training institutes for social work have been founded. Most of these developments are still in a very early phase.
Despite these positive developments, there have also been a number of negative facts of the disintegration of the Soviet Union. One of these sideeffects of the disintegration of the Soviet Union is the lack of university departments for psychology and social work in some of the new independent republics, and to study in another republic has become rather difficult. This is probably one of the reasons why there are still very few qualified psychotherapists. The increasing popularity of unofficial healers and witch-doctors may be partly explained by this situation.
During the past years we have witnessed a convergence between East and West, not only in the political arena, but also in other fields, such as, for example, psychotherapy. In many ways the former Soviet Union and Western countries appear to be moving toward one another. Practical developments, such as the disintegration of the Soviet Union, on the one hand, and a development toward more unity in the European Union, on the other, seem to find a counterpart in psychotherapeutic trend. In Russia, the changes are taking place from directive towards nondirective working styles, with an increasing popularity of schools like Ericsonian hypnotherapy and psychoanalysis. In contrast, in many Western countries, directive forms of psychotherapy, such as behavior therapy and cognitive therapy, are becoming increasingly popular. For some disorders, dynamic psychotherapy is rapidly becoming obsolete, and is replaced by pedagogical methods, e.g., psycho-education for schizophrenia. Also, Western psychotherapy is increasingly being directed toward specific psychiatric disorders, instead of toward general goals such as "personal growth." Where in Russia, other disciplines are entering into the field next to the medical profession, in countries, such as in Great Britain and the Netherlands, the medical model seems to be strengthened and psychiatrists are regaining their central position in the field of mental health.
These changes in the field of psychotherapy can hardly be interpreted as developments in the scientific sphere. Rather they should be viewed from the historical and cultural context within which they occur. They demonstrate once more that psychotherapy and the concepts and models it uses are above all exponents of the prevailing cultural values.20 The enormous political changes having taken place in Eastern Europe during the past five years will certainly also leave their trace on the field of psychotherapy, both in the East and in the West. Primarily one may expect that many of the Western values, which promote individual growth in accordance to the prevailing values of liberalism and capitalism, will strongly influence the psychotherapeutic culture of Russia. It will also be interesting to see whether influences from Russia will be discernible in Western psychotherapies in the near future. One interesting aspect of Russian psychotherapeutic theories, which has received relatively little attention in Western theory, is the role of language and its historical and cultural signposts as important determinants of mental processes.
The increasing rate of exchanges between psychotherapists from the new independent states of the former Soviet Union and Western countries now allow an in-depth comparison of concepts and methods of psychotherapy in these countries for the first time. Even though in both parts of the world common roots can be traced to the founders of psychotherapy in the previous century, the political and sociocultural circumstances during later years have fostered the development of marked differences in philosophy and style. Psychotherapy in Russia, as it emerged during the communist era under conditions which were generally unfavourable to the field, gives much greater emphasis to social determinants of mental problems, and hardly focusses on individual growth and well-being as goals of treatment. Related to this, psychoeducation, suggestion, and a directive approach play a more important role in Russia, whereas stimulating insight and a nondirective attitude are traditionally more characteristic of Western psychotherapeutic practice. During the past years, and especially since the disintegration of the Soviet Union, these differences tend to become smaller. The convergence between Russian and Western psychotherapy is increased by a gradual shift toward more directive and pedagogical approaches in the West. Such developments on both sides of the former divide demonstrate the enormous impact of prevailing cultural values on the theory and practice of psychotherapy in general.
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*Department of Psychiatry, University Hospital Utrecht, Utrecht. The Netherlands; Mailing address: AZU Divisie Psychatrie, Postbus 85500, 3508 GA Utrecht, The Netherlands.
**Psychiatric Hospital Veldwijk, Ermelo, The Netherlands
***Department of Clinical and Health Psychology, Utrecht University, The Netherlands
****Psychiatrist in private practice, Moscow…
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Publication information: Article title: Psychotherapy in Russia: Historical Backgrounds and Current Practice. Contributors: Havenaar, Johan M. - Author, Meijler-Iljina, Ludmila - Author, van den Bout, Jan - Author, Melnikov, Alexander V. - Author. Journal title: American Journal of Psychotherapy. Volume: 52. Issue: 4 Publication date: Fall 1998. Page number: 501+. © American Journal of Psychotherapy 2008. Provided by ProQuest LLC. All Rights Reserved.