Up until 1989 Bulgaria was a communist country with a Soviet-style totalitarian government. Now it is a parliamentarian democracy and a member state of the European Union, but it is still a poor country: a significant proportion of the population lives below the poverty line and unemployment is high everywhere except in the capital city, Sofia, and the Black Sea region.

In February this year social unrest, in response mainly to poverty and high electricity prices, brought about the resignation of the right wing Government and led to snap elections in May. Matters were so bad that the President, Rosen Plevneliev, called on all the country’s faith leaders to hold three days of special prayer, after seven people set themselves on fire in protest at the poverty and corruption and five of them died.

There is a widespread discontent with the whole political system. In the newly elected parliament the majority belongs to the so-called ‘Frankenstein coalition’ between the Socialists (former Communists), the party of the Turkish minority, and its archenemy, the ultra-nationalist Atacka party.

Totalitarian rule caused a slowdown in the development of Bulgarian society as a whole, and this relative immaturity is reflected in the immense difficulties accompanying the transition to democracy and especially in the spiritual and mental aspects of social life. It is in this context that the history and current status of psychological help in Bulgaria can be best understood.

Even before World War II, a small number of intellectuals in Sofia were interested in psychoanalysis and psychotherapy. Some Bulgarian psychiatrists created psychotherapeutic methods of their own, reminiscent of hypnosis and the cathartic therapy that Sigmund Freud applied before he discovered psychoanalysis. However, psychotherapy and counselling did not develop in Bulgaria until the end of the 20th century.1, 2 This was because during the Communist era psychology and psychotherapy were declared ‘bourgeois science’, incompatible with Marxist philosophy, and were banned from universities. Students have been able to study psychology at Sofia University since the early 1970s, but training in psychotherapy – and in any kind of clinical psychology – remained unavailable until the fall of Communism.2

Mental healthcare

In general, mental healthcare generally in Bulgaria is lagging behind much of the rest of the world. As mentioned, there was no psychology during the Communist regime and psychiatry was the black sheep of medicine. Bulgarian psychiatric hospitals were in a deplorable condition, and psychiatrists were regarded (and sometimes also regarded themselves) as second-rate doctors. When I started my professional career back in 1981 there were only four or five psychologists employed in psychiatric clinics, and only two or three of them had training in psychology; the others were graduates of other professions. Psychologists were asked to perform psychological testing, but not psychotherapy or any other psychological intervention, and patients were treated with medication only.

Unfortunately the situation has not changed very much today. Some of the psychiatric hospitals are reminiscent of 19th century asylums, and the number of psychiatrists is decreasing. The number of clinical psychologists and clinical social workers has remained as small as it ever was. As a rule, a state psychiatric clinic will employ one clinical psychologist and one clinical social worker. What has changed, however, is the involvement of private practices and non-governmental organisations in helping people in mental distress, to which I will return later.

According to Eurostat and the World Health Organization, Bulgaria has the lowest health spending per capita in the European Union. The spending on mental health is about two per cent of the health budget – much lower than in other countries. So, although the mentally ill receive high quality medication, there is an almost complete lack of other forms of care such as psychotherapeutic support, social services, day care centres etc. In fact, many psychiatrists, even when working in private practice, would not refer their patients to a psychotherapist.

In the same vein, governmental institutions seem to be unaware of the existence of counselling and psychotherapy: there is no government funding for these activities and nor are they covered by health insurance.

Developments in psychotherapy

Despite this unfavourable situation, psychotherapy and counselling have managed to undergo rapid development, particularly during the last 10 years. In 2013, thanks to efforts by mental health professionals, the National Classification of Occupations, issued by the Ministry of Labour and Social Care, for the first time included ‘psychotherapist’ as a recognised profession, alongside ‘family and marriage consultant’ and ‘child and adolescent consultant’. However, there are still no training programmes for counsellors, and among mental health professionals counselling is regarded as one of the services offered by psychotherapists, psychiatrists and clinical social workers. Some therapy organisations, such as the Bulgarian Association of Cognitive-Behavioural Psychotherapy, offer training courses for counselling that are shorter versions of their psychotherapy training (eg 600 hours instead of 1,200), but they are only open to people with a relevant degree in, for example, psychology or social work.

In 1989 there was not a single psychotherapist in Bulgaria trained to any recognised standards. In the 1990s several psychotherapeutic schools sprang up in the country looking for people interested in becoming psychotherapists. They found themselves on fertile ground because there was already a group of young professionals who had been practising psychotherapy ‘underground’ since the late 1970s3 and were ready to start their training. These professionals, of whom I was one, included psychologists and psychiatrists working in psychiatric clinics. We had no proper training in psychotherapy, relying instead on books and peer supervision, and sporadic meetings with Western psychotherapists. Each Friday we would meet to discuss clinical cases and theory. We worked mostly with patients from the mental health clinics, but the psychotherapy was not ‘officially’ prescribed to them and was not included in their medical records.

Today we have training programmes in the following approaches: psychoanalysis, Lacanian psychoanalysis, group analysis, Jungian analysis, cognitive behaviour therapy and systemic family therapy. Humanistic therapies include psychodrama, body psychotherapy, positive psychotherapy, brief psychotherapy and music therapy.

Gestalt therapy and transactional analysis are the latest developments. Training in these approaches started just a couple of months ago. Although there are some individuals trained in the person-centred approach of Carl Rogers, there is no training programme yet in this modality. Other methods practised in Bulgaria are hypnosis, NLP and transpersonal psychotherapy.

This flourishing of newly- fledged training programmes should not, however, lead to the deceptive conclusion that at last there are enough psychotherapists in this country. In fact fewer than 100 therapists have finished their training, and the country needs many more.

Today talking therapists – psychotherapists, psychologists or clinical social workers in their capacities both as psychotherapists and counsellors – work predominantly in the private and the non-governmental sectors. As well as individual and group practices there are also a number of private clinics and non-governmental organisations working with drug addicts. Drug addiction is probably the most severe mental health problem in Bulgaria, at least in terms of the number of people affected. There are also centres dealing with family violence, battered women and victims of political persecution. These non-governmental organisations employ more clinical psychologists and social workers than the state mental health system, and they also offer counselling services as well as psychotherapy. There are also a few university counselling centres, such as at the American University in Blagoevgrad. The number of psychologists in schools is slowly increasing, and some kindergartens, too, employ psychologists. ‘Schools for parents’ – educational forums where qualified psychotherapists teach parents about the psychological aspects of the parent-child relationship and the possible psychological problems that may arise – are becoming more and more popular.

During the last couple of years the health system and the state system of social services too have become more open to psychological services.

There are many children in institutions in Bulgaria. They are mostly orphans and abandoned children but also children with severe disabilities such as Down’s syndrome or cerebral palsy. The living conditions in these institutions are sometimes appalling. In the Communist era, the prevailing attitude was that such children should be kept away from the rest of society and remain ‘unseen’. In recent years some psychotherapists and clinical social workers have drawn attention to the fact that these children are suffering psychologically and need help. The Bulgarian Government has now put forward a national strategy, part EU-funded, aimed at closing down the institutions and providing the children with the opportunity to live with foster families or adoptive families, if possible.

Psy-stigma

Psychotherapy and counselling have increasingly attracted public attention, partly because of growing media coverage and the numbers of internet sites dedicated to psychology and mental health, but also because many mental health professionals have been and are involved in the realisation of various projects sponsored by the European Union and other organisations. But it would be an exaggeration to say that the talking therapies in Bulgaria are well known to the public and easily accessible. There is a ‘psy-stigma’: everything beginning with ‘psy-’ is associated with shame. Many people think: ‘I am not crazy, why should I go and see a psychotherapist?!’ This equating of psychological problems with ‘craziness’ is partly due to the absence of psychology in the public discourse during the last decades. Obviously there are more people who know about psychotherapy in the capital city of Sofia and in the larger cities than in the small towns and villages, and people over 60 seem much less well informed than younger people.

Despite the progress in the professionalisation of psychotherapy, there are still many unqualified people who offer therapy or ‘psychoanalysis’. Some of them don’t even have a college education. However, in Bulgaria, if you call yourself ‘an extrasensory healer’ or a ‘clairvoyant-psychotherapist’ you stand a good chance of attracting more clients and setting much higher fees then a well-trained psychotherapist. Less educated people (and these are the majority in Bulgaria) would see an extrasensory healer in preference to a psychotherapist. Magical beliefs are common in the population. For example, an old blind woman who died in the 1990s was believed to be a clairvoyant and declared a saint. A church was erected near her home and is now a site of pilgrimage.

Standards and regulation

The only professional umbrella organisation for psychotherapy in Bulgaria is the Bulgarian Association of Psychotherapy (BAP). When it was founded back in 1993 it was called the Bulgarian Association of Psychotherapy and Psychological Counselling. This was because the founding members included some school psychologists and the idea was to create links between school psychology and clinical practice. Soon afterwards the Government for some reason decided to replace the professional title ‘school psychologist’ with ‘educational consultant’, with the result that many non-psychologists were appointed and many psychologists lost their jobs. Later on, after BAP became a member of the European Association of Psychotherapy (EAP) and adopted its rules, it removed the ‘counselling’ element from its name. The new name described it more accurately as the school psychologists had already left the organisation.

Nowadays BAP has more then 100 individual members – psychotherapists and psychotherapy trainees – and almost all psychotherapeutic societies representing the different modalities are group members. It holds annual meetings that attract hundreds of attendees. Besides forging connections within the psychotherapeutic community, its main goal is legislation to make psychotherapy a regulated profession.4 The legal drafting is in progress, and BAP is lobbying parliament in an attempt to ensure the legislation reflects its views. The legislation would include minimum standards for the training of psychotherapists, rules for the accreditation of training programmes, and requirements for the conditions for practising psychotherapy.

Other professional organisations open to counsellors and psychotherapists include the Bulgarian Psychological Society, which maintains a National Referral Bureau for psychological services; the Society of Practical Psychology; several psychiatric organisations, such as the Bulgarian Psychiatric Association, and a number of professional bodies for social work, the largest of which is the Bulgarian Association of Social Workers (BASW).

On the subject of fees, neither psychotherapy nor counselling are covered by health insurance; clients have to pay for therapy themselves, unless the services are provided within a sponsored project. Any free psychological counselling is offered predominantly by non-governmental organisations. In the last few years, however, it has become commonly accepted that victims of natural or man-made disasters, those injured in major traffic accidents and victims of school violence should get free psychological counselling as crisis intervention. So this has become probably the most conspicuous psychological activity from the point of view of the Government.

It seems quite likely that in the near future the number of those who wish to become counsellors or psychotherapists in Bulgaria will increase. There are a lot of training programmes already in place, but people refrain from applying for training because they fear they will not be able to earn enough to make a living if they work in this field. However, the professional identity exists, even if it is currently difficult to predict if counselling will assert itself as a separate profession, distinct from psychotherapy. In any event, we hope that soon the talking therapies will become regulated professions and that this will lead to further improvement of the quality of service and the image of the mental health field within Bulgarian society.

Nikola Atanassov is an Associate Professor of Clinical Psychology at the New Bulgarian University in Sofia. He is a psychoanalyst, a member of the International Psychoanalytic Association and an Interim Training Analyst of the Bulgarian Psychoanalytic Society. From 2006 to 2009 he was the President of the Bulgarian Association of Psychotherapy. www.nikola-atanassov.org

References

1. Tomov T, Atanassov N. Psychoanalysis in Bulgaria. In: P.Kutter (ed). Psychoanalysis international: a guide to psychoanalysis throughout the world, vol 2. Stuttgart: Frommann-Holzboog; 1995.
2. Atanassov N. Bulgaria. In: Pritz A (ed). Globalized psychotherapy. Vienna: Facultas; 2002.
3. Atanassov N. Freud’s einfluss auf die Bulgarischen medizin, philosophie und literatur. In: Toegel C, Frommer J (hrsg). Psychotherapie und psychoanalyse in Osteuropa. Uchtspringe: Sigmund Freud Zentrum; 1996.
4. Atanassov N, Stantchev D, Tarashoeva G. Psychotherapy as a profession. Papers from the 4th National Congress of Psychology (in Bulgarian). Sofia: Sofia R Publishers; 2005.