Colin: In some ways Bulgaria’s position regarding psychotherapy and counselling resembles the state of play in the UK about 40 years ago and also that of other countries with an emerging minority interest in talking therapies. Do you think there’s an inevitable time lag like this, or is there some way for Bulgaria to significantly speed up developments?
Nikola: I can’t see any specific factors that could make developments in Bulgaria faster than in other countries. We could maybe save some time by learning from the experience of others and being able to avoid some of their mistakes or some tumbling in the dark. But 40 years ago the UK was a developed society with a strong economy, and Bulgaria today is an underdeveloped society with a weak economy. And in the early 70s some of the psychotherapies in the UK had gone a long way: take psychoanalysis for instance.
But I don’t want to be a prophet of doom: maybe we will be able to catch up with the advanced countries faster then it seems possible now. Before the world financial crisis the Bulgarian economy had an annual growth of 4.8 per cent – much higher than in the Western part of Europe. And the Bulgarian psychotherapeutic profession managed to start training programmes in all important branches of psychotherapy within about 20 years, whereas in other countries it took several decades for the same processes to evolve.
In this vein I think that the introduction of legislation for psychotherapy could speed up developments by raising the social status of the profession.
I think the development of the UK counselling scene was characterised by the early contributions of the voluntary sector, followed by counselling in education and business and lastly by government health departments. What are the similarities and differences in Bulgaria?
Bulgaria has no strong voluntary sector, for historical reasons. Under Communist rule, there was a dogma that the state can take care of all its citizens, so charity is not needed. As a consequence, there was no voluntary sector to make a contribution to the development of counselling. In the 80s counselling was offered by some doctors and psychologists working in governmental health departments. The changes in 1989 made possible the appearance of organisational and school counselling provided by psychologists. At the same time there was rapid growth in private practices and non-governmental organisations offering counselling for various problems related to mental health. During the last couple of years the governmental agencies have become more active in the sphere of child care, drug abuse, crisis intervention etc.
You mention training hours of 600 and 1200 but BACP’s requirement for accreditation is shorter than these, and I wonder how such figures are decided?
They are decided by the societies, organising the training. The hours mentioned above are the requirements of the Bulgarian Association for Cognitive-Behavioural Therapy (BACBT), and their programme is based on the standards of the European Association of Behavioural and Cognitive Therapies (EABCT). But almost all psychotherapeutic societies in Bulgaria are group members of the Bulgarian Association for Psychotherapy (BAP): ie they have accepted its training standards and are trying to meet them. The BAP has adopted the training standards of the European Association for Psychotherapy (EAP) that require at minimum 3200 hours training to become a psychotherapist, at least 1400 hours of which should be training in a specific modality (eg CBT).
As I mentioned in my article, a counselling profession close to the model of the BACP has not yet been considered in Bulgaria.
Presumably (related to the above) the relatively limited interest in therapy training is affected by economics, ie that not many can afford a long training?
Yes, it seems quite probable that if there were shorter ways to reach the clients there would be more applications for training. The psychotherapists in Bulgaria have been and still are very much concerned with the necessity to create training programmes that meet the highest international standards. We believe that they should be the solid basis for professional services in the field. Then we will have to expand our network of services to be able to support more candidates for training and a greater variety of training choices.
It’s interesting that in your article you say some home-grown Bulgarian models of psychotherapy have been based on hypnotherapeutic and cathartic methods, and also that ‘extrasensory healing’ and ‘clairvoyant psychotherapy’ are well regarded. In the July ‘In conversation’ interview on traditional healing methods in the Toronto area, Roy Moodley was very positive about these as part of a pluralism of therapies. I gather you don’t feel the same way?
I support a pluralism of therapies. It is a worldwide phenomenon that the psychotherapeutic services reach a small portion even of those who would very possibly benefit from them and can afford them: eg middle class people with emotional disturbances living in urban areas. The vast majority would for various reasons not go and see a psychotherapist, especially in the case of long-term therapy.
From this point of view I am in favour of the existence of alternative treatment methods. I am not an expert on traditional healing and its efficacy, but I know that the historical prototype of my profession is the medicine man or the shaman. As far as the extrasensory healers and the clairvoyants in Bulgaria are concerned, however, I would be very cautious to compare them with shamans. The Bulgarians adopted Christianity in the 9th century, and even though traditional healing practices existed, it is questionable how far the extrasensory healers use them. Most often they claim to be endowed with a higher power and to possess supernatural capacities. I don’t know if they have been helpful to some people, but many of them have been exposed as impostors. There is a lot of malpractice in this field.
The professional community preparing legislation for psychotherapy is concerned to protect the title ‘psychotherapist’. In the draft legislation this title is reserved for people who have completed training in psychotherapy on an accredited programme.
The UK imported person-centred counselling training models from the US in the 1970s and other countries have since imported UK or BACP norms for training (eg Kenya) and supervision (eg Australia). Can this importing of models and norms work in Bulgaria?
I am not really familiar with the counselling training models that are currently being used in the UK. But looking back to the history of psychotherapy in Bulgaria that I outlined in the article one can see that we have been moving forward by importing models. A British psychotherapist – Diana Waller – was visiting Bulgaria in the early 80s and she was one of our first trainers. Later in the 90-ies some training programs (CBT, systemic family therapy) were organised in collaboration with British institutions. Group relations conferences in Sofia were led by British experts. So I can imagine that if we start to develop training models of counselling as a separate profession we might also learn from the rich experience of the UK or BACP.
Some of us believe that competition between mental health professions and multiplicity of theoretical models impedes the development of best service delivery to clients and should be avoided if possible (but is bogged down by decades of tradition). Is it possible to avoid these problems in Bulgaria?
The development of the mental health professions in Bulgaria is in its initial phase. The good thing is that at least at the moment the competition between the psychotherapeutic schools does not prevent them from talking to each other. They all recognise BAP as the umbrella organisation and within such an organisation it should be possible to maintain a fruitful dialogue.
More problematic seems to be the communication with psychiatry. Many of the so-called biological psychiatrists seem to have no interest in working with psychologically oriented professionals. At present I am not optimistic that we can avoid these problems. On the other hand, we even now have a lot of examples, for instance with the treatment of drug addictions, of a relatively smooth co-operation between different mental health professions and different institutions (eg private clinics and NGOs).
There is also the question of statutory regulation, how helpful or not it is and whether good alternatives exist. The UK scene has been characterised by just such problems for many years. Can Bulgaria avoid such complications and delays?
The draft legislation has been open for debate for nearly two years now. The efforts to introduce statutory regulation have not met any significant resistance. The talking therapists are quite unanimously in favour of statutory regulation. The prevailing attitude is that if psychotherapy is a regulated profession it would be easier to protect the clients (or help the clients protect themselves), and the profession would have a higher prestige and be more attractive as a career.
The complications and delays could be the result of a lack of responsiveness from the legislative bodies, especially if we take into account the volatile political situation.
What’s the current state of play, and plans? Who is representing objectives and proposals to relevant government departments and what progress is being made?
As far as the legislation is concerned, the BAP has organised a working group including representatives of the state health department, of other relevant organisations, a lawyer etc. The prepared draft has been discussed with the psychotherapeutic societies and is available for further discussion on the BAP website. A Member of Parliament who is a psychologist and a certified psychodrama-therapist has taken upon herself the task of lobbying for the law on psychotherapy and taking it to the relevant parliamentary committee.
Bulgaria is a poor country experiencing social unrest, high unemployment, low wages and relatively low life expectancy. Doesn’t this raise the problem of priorities – that people may not be primarily interested in psychotherapy when more basic needs remain to be addressed?
Yes, I am quite sure that there are many people who think that psychotherapy could be useful for them but stay away because they cannot afford it. This of course refers especially to long-term therapy, but even 25–30 sessions can be a great financial burden for many people, too. Given that the average monthly salary – according to official estimates – amounts to around E400 and the costs of living, albeit somewhat lower, are comparable with the EU average, it is understandable that most people here should very carefully calculate their expenses. But at the same time the social misery may be conductive to the use of projective defence mechanisms: ‘It is the world outside that has problems, it’s not me’.
I’m curious about the relationship between erstwhile Bulgarian ‘bourgeois science’ and current politics on the one hand, and the development of its (individualistic?) psychotherapy on the other. Wilhelm Reich and to some extent Erich Fromm tried to blend Marxist with psychoanalytic theories, and today’s critical psychologists attempt to reach out beyond therapy’s individualistic focus. Is there any taste for such developments in Bulgaria?
In Bulgaria there are psychotherapists who are actively engaged in social processes. During our psychodrama training we also learned sociodrama as a tool to work with relationships between social groups. Some psychodrama-therapists who later also became psychoanalysts of the Lacanian orientation founded the Assistance Centre for Torture Survivors (ACET) to work with victims of the Communist concentration camps; today they help refugees from foreign countries. Some psychological centres (the biggest one of them is called the Animus Association) are concerned with family violence and human trafficking. Clinical social work programmes try to focus on intrapsychic, interpersonal and social conflicts simultaneously. Adherents of the systemic approach especially understand psychopathology as a supra-individual process and believe that social change has therapeutic value as well. They work with families, but also create political initiatives and take part in political movements.
Some psychotherapists and psychoanalysts are active in the current street protests against the new Bulgarian government that started in June and are still ongoing.
You say that private practice is available but mainly in places like Sofia and presumably quite expensive. Again this reflects developments elsewhere and it seems inevitable that areas with low population cannot sustain either significant private practice or even state-supported services. Do you agree with this in the Bulgarian context?
Yes, I agree. As a matter of fact even in Sofia only a few psychotherapists can sustain themselves by private practice only. In the rest of the country you can find private practices mostly in some regional centres (in Bulgaria these are townships with 70,000–350,000 inhabitants). As an exception there are some practices in smaller places, too, but it is highly improbable that they manage to attract enough clients; in all cases they are part-time practices.