by Nikola Atanassov Ph.D.
Bulgaria is a South-East European country with about 7 900 000 inhabitants. A communist country in the recent past, since 1989 Bulgaria has been a parlamenrary democracy; its new Constitution was adopted in 1991. In 2000 the GDP was $ 12 bln., which makes $ 1459 per capita (source: www.seeurope.net). In the same year 35% of the population lived below the poverty line. The inflation rate was 10,4 %, and 17,7 % were unemployed.
1. History
In 1878 Bulgaria reemerged as a separate state after having been a part of the Ottoman empire for nearly 500 years. During this time the Bulgarians had managed to preserve their Christian identity, although the Ottoman rule had brought the country to extreme backwardness. The vast majority of the population were illiterate, there were but a few schools, a few teachers, no hospitals and no doctors. The few educated Bulgarians had studied abroad, primarily in Russia. The first Bulgarian University was inaugurated in 1889. The first asylum for mentally ill people opened also in 1889 (Millenkov&Poppov, 1983); in 1902 there were only two psychiatric wards and one asylum (Danadzhijev, 1912) in a country with more then 4 million population.
The decades after the Liberation were for Bulgaria a time of rapid growing links to the rest of Europe in an effort to catch up with the more advanced countries. For Europe the same decades were a time when psychology and psychoanalysis emerged. Remarkably, a number of young Bulgarians, who went abroad to study, were inspired by these new ideas. There were six of them who studied psychology with Wilhelm Wundt in Leipzig (Tögel, 1983). The psychiatrist Nikola Krestnikoff studied in Paris and in Saint Petersburg and became interested in the treatment by psychological methods. Shortly before World War One Mladen Nikolov finished his post-graduate studies in psychology at Berlin University and became interested in psychoanalysis.
In 1921 Dr. Nikola Krestnikoff initiated the foundation of the Psychological Society in Sofia. Among the 7 members were two Russian émigrés, one of whom was a professor in psychiatry, and the other one – a professor in sociology. Other members included two psychologists, one of whom was a student of Wundt, and a lawyer. Dr. Mladen Nikolov was also among the members, as was – of course – Krestnikoff himself.
It seems that, at least in the beginning, the predominant topic at the meetings of this society was the use of psychological methods to treat sick people. Krestnikoff referred patients to Nikolov who analyzed them and then reported the treatment to the society. There is no written record of his method of work and it is hard to say what exactly he was doing. According to Kinkel (1922) at least some of Dr. Nikolov patients had ample delusions; it was at the time when Sigmund Freud himself considered the psychoanalysis of psychotic patients impossible. Although Freudian in his approach, he also applied “the association test” of C.G.Jung. It seems that he – and his colleagues at the meetings of the society – tried to interpret the underlying meaning of the patient’s associations without considering resistance and transferance, in a manner resembling the way of work of Freud`s first disciples.
One of the members of this group – the sociologist Ivan Kinkel – gained international recognition for his paper “On the psychological basis and origins of religion” (Kinkel, 1922) that was published in the psychoanalytic journal “Imago” and later translated into Swedish and Russian. This paper deals with the possibilities to apply the method of psychoanalysis to the explanation of the origins of religious beliefs. Strongly influenced by Freud`s “Totem and Taboo”, it contains ample reference to the myths and legends of the Slav people, notably the Bulgarians and the Russians. It was on the basis of this paper that Kinkel was accepted a member of the International Psychoanalytic Association. Later on he published a voluminous scientific work on the same subject.
The Psychological Society in Sofia had a short life. Soon the differences of opinion between its members became irreconcilable. The dividing line, it seems, was the attitude towards psychoanalysis. The two psychologists, who did not work with patients, renounced psychoanalysis, considering it incompatible with experimental science. Dr. Krestnikoff, who initiated the foundation of the society, developed a psychotherapeutic method of his own, which was akin to the cathartic technique of Breuer and Freud from the pre-psychoanalytic area. He called it “reproduction of pathogenic affective experiences” (Krestnikoff, 1929). In short, this method is based on the assumption that the emotional disturbance is caused by a forgotten memory; the method aims at reproducing the memory including the accompanying bodily sensations and the affective experience. The technique is based on the premise that in a relaxed atmosphere (the doctor putting his hand on the patient’s forehead) the patient after a few minutes would spontaneously revive the bodily sensations connected to the pathogenic experience and then the doctor, by asking questions, would help him remember the emotional and ideational components of the memory.
It seems that Dr. Mladen Nikolov continued to analyze patients in the late 20-ies and during the 30-ies. In the 30-ies the few adherents of psychoanalysis in Bulgaria tried to organize a new group that remained active until the start of World War II. One member of this group summarized its activities in the following sentence: “ By papers and discussions, psychoanalyses and hypnoses we tried to satisfy our thirst for knowledge” (Andreev, 1946, quot. in Atanassov, 1996). It seems, however, that this group was concerned primarily with making psychoanalysis known to the general public. The members wrote articles, gave interviews to newspapers and magazines and held public lectures. Their papers, much like the ones of the first group during the 20-ies, were written in an objectivistic language; psychoanalytic structures were talked of as if they had a substantive reality (see also Tomov and Atanassov, 1995). Inner reality seemed to be as accessible from the point of view of the positivist science as the external one was.
Apart from the psychoanalytic circles, two other prominent Bulgarian psychiatrists developed during the 30-ies psychotherapeutic techniques of their own. Kiril Cholakov called his technique – a version of hypnosis – “decapsulation”, while Nikola Shipkovensky`s method was called “liberating psychotherapy”; as the name implies, this method aimed at achieving catharsis.
To summarize, during the 20-ies and 30-ies of the last century the practice of psychotherapy in Bulgaria was reminiscent of Joseph Breuer`s and Sigmund Freuds pre-psychoanalytic techniques – hypnosis and catharsis, on the one hand, and of the “wild” analyses of Freud`s first disciples, on the other. Psychotherapy was applied only by a few individuals, mainly in psychiatric wards. No one of them had training in psychotherapy: the ones who practiced “psychoanalysis” did not have personal analysis, and the others applied methods developed by themselves.
The World War Two and the communist regime afterwards managed to completely prevent the further development of psychotherapy in Bulgaria. In the 50-ies psychoanalysis, as well as psychology, were officially declared unscientific, and a vulgarized (“Marxist”) version of the Pavlovian reflexology became the only “science” of human behavior. Its main dogma was that there is no psyche, there is only the activity of the higher nervous system based on innate and conditioned reflexes. However, even in the 50-ies and in the 60-ies a few psychiatrists continued to practice psychotherapy: Krestnikoff“s son Angel Krestnikoff applied the original “reproduction method”, while Atanas Atanassov practiced a modified version of it, which was based on the Pavlovian reflexology.
In the 60-ies the psychiatrist Christo Dimitrov became the link between the pre-war psychotherapists and the new generation that was destined to introduce modern psychotherapy to Bulgaria. Dr. Dimitrov lost his sight after a brain operation and so he was prevented from continuing his psychiatric carrier. He was charged with criticizing psychoanalysis from the point of view of Marxism. In order to fulfil this task he gathered together a group of young psychiatrists who were instrumental in finding the psychoanalytical texts and reading them to him (Kamen, 1992). By doing so they were able to learn more about psychoanalysis and to translate some basic psychoanalytic concepts into Bulgarian. One of these young psychiatrists was Nikola Kolev. In 1968 he immigrated to Sweden; later he became a training analyst of the Swedish Psychoanalytic Society[†].
Another of Dr. Dimitrov`s colleagues – Georgi Kamenov – became interested in psychoanalytic group therapy. He was encouraged by the Swiss group psychotherapist Raymond Battegay to apply group therapy as a substitute for individual psychoanalysis. In 1973 he got an appointment at the Medical Academy in Sofia; there he started working with a small group of students, giving them some basic training in group therapy and teaching them basic psychoanalytic concepts like transference and countertransference, training analysis and supervision. In this way he motivated a new generation of psychotherapists, many of whom play an important role in contemporary Bulgarian psychotherapy.
Dr. Kamenov`s activities were regarded as potentially dangerous by the official authorities. He was subjected to persecution and left the country in 1978. Nowadays under the name of George Kamen he works as a psychoanalyst in New York City.
After Dr. Kamenov`s departure his students founded a standing seminar on psychotherapy which remained active until 1985. The participants met every Friday afternoon to present clinical cases, to discuss theoretical problems and to practice peer supervision (in a way their activities were reminiscent of the Psychological Society of the 20-ies). By that time mainly group therapy was applied, influenced most of all by the interpersonal approach of Irvin Yalom. These young psychotherapists managed, despite all the difficulties, to maintain contacts with a number of psychotherapists abroad. Notably Diane Waller from London visited Bulgaria several times and worked with her Bulgarian colleagues.
In 1984 two prominent Greek family therapists, George and Vasso Vassiliou, visited Bulgaria; their visit laid the foundation of a long lasting working relationship with some Bulgarians, which continues into the present. More contacts were made at the international congresses of group therapy (Zagreb, 1986) and family therapy (Prague, 1987). Some psychotherapists of the previous generation like Atanas Atanassov and Alexi Alexiev participated at the activities of the so-called Working group of the psychotherapists of the socialist countries, which was the official international body of the communist-era East-European psychotherapy. In October 1988 this group held its annual meeting in Sofia, and on that occasion the first international conference on psychotherapy in Bulgaria was organized, attracting a number of participants from Western countries.
Thanks to the efforts of the young professionals mentioned above to attract international trainers in April 1989 a psychodrama training programme involving 10 participants was started in Sofia. This programme was supported by the National Neuroscience and Behavior Research Programme and the executive secretary of this programme – Dr. Toma Tomov – was among the trainees. The trainers were Gabrielle Wiesmann-Brun from Switzerland and Göran Högberg from Sweden. Although this training ended in 1994, the trainers still keep up their contacts with Bulgaria (e.g. Gabrielle Wiesmann-Brun is now supervising some of her former students).
2. Training situation
From what was mentioned in the previous section it becomes quite obvious that the establishment of the practice of psychotherapy in Bulgaria is still in its early stages. To summarize: until 1994 nobody in this country had formal training in psychotherapy. In 2001 several training programmes are underway in cooperation with international bodies representing psychotherapeutic modalities (see the next section for more details): a small number of Bulgarians were accepted as training candidates at the newly founded IPA East-European Psychoanalytic Institute and are about to start their training analyses in early 2002; a French-Bulgarian training project in Lacanian psychoanalysis is underway; during the last 3 years two members of the Bulgarian C.G.Jung Society have been undergoing personal analysis and working under supervision; two private institutions offer training in psychodrama, recognized by the FEPTO (Federation of European Psychodrama Training Organizations); there is a training programme in systemic family therapy at the New Bulgarian University and a less structured training programme at the private SISEP institute; other projects include a 280 hours training course in Positive Psychotherapy (which, obviously, does not amount to a full training in psychotherapy), and a training programme in Neo-Reichian psychotherapy, based partly in Sofia and partly in Switzerland.
As mentioned in the next section, the other organized modalities (cognitive-behavior therapy, music therapy, and hypnosis) do offer training courses as well.
As a whole, there are only a few individuals who have completed training consistent with international standards, but even those who have, did so only a few years ago.
3. Main modalities
Psychoanalysis and psychoanalytically oriented psychotherapy
In 1991 a group of psychiatrists, psychologists, a historian and a philologist (6 persons altogether) founded the Bulgarian Psychoanalytic Society. Most of the members of this group were not interested in receiving psychoanalytic training; they were eager to work for the creation of an “receptive atmosphere for psychoanalysis” in Bulgaria. The group developed contacts with the International Psychoanalytic Association (IPA) and the European Psychoanalytic Federation (EPF), with the Center for Psychoanalytic Studies at the University in Kent and with the Institute of Psychoanalysis at the Goethe University in Frankfurt on Main, Germany. From this group the Human Relations Institute at the New Bulgarian University in Sofia emerged. In collaboration with British professionals from the Grubb Institute in London and from the University of Kent this Institute is organizing among other things group relations events following the model of the so called Leicester group relations seminars in the UK.
Another group emerged after the return of the Bulgarian psychoanalyst Krassimir Taoushanov, who was trained by the Paris Psychoanalytic Society. The members of this group maintain regular contacts with the IPA and the EPF and attend the so-called East-European Psychoanalytic Seminars and Summer Schools which offer ample opportunities of mutual exchange between Western training analysts and their East European colleagues. In 1995 the group introduced an exchange programme involving the French psychoanalyst from the Paris Society Gerard Lucas. Since then Dr. Lucas is visiting Bulgaria on a regular basis twice a year giving case seminars and consultations. Recently this group was officially registered under the name of Group for the Development of the Practice of Psychoanalysis in Bulgaria. Its members are interested in receiving full psychoanalytic training according to the standards of the IPA. Their distant goal is to establish a psychoanalytic society and institute in Sofia. Currently most of the group members are teaching at the newly founded Masters degree programme in psychoanalytically based clinical psychology at the New Bulgarian University.
As already mention in the previous section, there are a few Bulgarian candidates for full psychoanalytic training at the East European Psychoanalytic Institute.
Lacanian psychoanalysis: In 1997 the Psychotherapy 2000 Foundation (Chairs: David Yeroham, M.D. and Evgeni Genchev M.D.) organized a French-Bulgarian meeting on Lacanian psychoanalysis, inviting a number of pro-Lacanian analysts from Espace Analytique, Paris. Following three years of seminars a common project was started between the psychoanalytic group Espace Analytique (represented by Patrick Delaroche) and the Center for Psychosocial Support in Sofia; the French Foreign Office is rendering financial support (Dimitrova, 2001). The goal of the project is to train Bulgarians in the Espace Analytique approach; the activities include theoretical and case seminars, supervision, training analysis, clinical internships in Paris etc.
Starting in 1999, Vessela Banova Ph.D., a child psychologist, has organized a Lacanian psychoanalytic training seminar programme called “To grow without parents” for people working in the so called Mother and Child Homes.. The programme is lead by members of the Lacanian society “Champes Freudienne” with the personal involvement of Lacan’s daughter Judith Miller. Some of the participants are already involved in personal analysis.
The Karen Horney approach: Couple of years ago the psychologist Kalina Nacheva graduated from the psychoanalytic psychotherapy programme of the Karen Horney Institute in New York City. Until recently she had a private practice in Sofia and was giving introductory lectures in the Horney approach at the New Bulgarian University.
Psychodrama
In the early 90-ies Gabrielle Wiesmann-Brun initiated the formation of two further psychodrama training groups which became known as Sofia II ad Sofia III. The teachers working with Sofia II changed pretty often, but at the end Jorg Burgmeister from Switzerland was the main teacher. Sofia III mainly worked with Ella-Mae Shearon and Bernhardt Achterberg from Germany (Stanchev, 2000). During the years teachers from other countries like Canada, Argentina, Belgium, Australia and the USA had been taking part in the training. The present Bulgarian psychodramatists hold diplomas issued by three institutes that are members of the Federation of the European Psychodrama Training Organizations (FEPTO) (Tarashoeva, 2000).
In 1990 the Bulgarian Society for Psychodrama and Group Psychotherapy (BSPGP) was founded by the members of Sofia I. Later the other two groups joined. The BSPGP is the national branch of the Psychodrama Institute for Europe seated in Munich, Germany. In 1993 the BSPGP organized in Sofia the Second Annual Meeting of this institute. In 1998 the society adopted standards for training in psychodrama, consistent with international criteria (Tarashoeva, op.cit.). However, training in psychodrama conducted by Bulgarian trainers is still in its early stages. There are two institutions that are members of FEPTO: the Orpheus Psychodrama Center and the Psychotherapy 2000 Foundation. The diplomas issued by these institutions are recognized by FEPTO. The Orpheus Center is member of the International Association of Group Psychotherapy (IAGP) as well.
Systemic Family Therapy
As mentioned above, systemic family therapy was introduced in Bulgaria in the 80-ies by the Greek family therapists George and Vasso Vassiliou from the Institute of Anthropos in Athens. The first to decide to follow the carrier of a family therapist were Zhenja and Roumen Georgiev, who were students of Georgi Kamenov and members of the standing seminar (see previous section). The two of them continued their education for nearly 15 years. In 1994 they founded the Sofia Institute for Social Ecology of the Personality (SISEP) which since then has been conducting a training programme in systemic family therapy and working on several projects on community based services. In 1994 Jeffrey K. Zeig, a student of Milton Erickson, was invited by them to Sofia. Upon his visit the Milton Erickson Institute of Sofia was founded, which aims at promoting Ericksonian approaches in Bulgaria.
In 1995 a university based training programme in systemic family therapy was introduced at the New Bulgarian University in Sofia. Zlatka Michova Ph.D., a member of the above mentioned Human Relations Institute, organized this programme in collaboration with the Institute of Family Therapy and the Tavistok Clinic in London (Michova, 2000). Now it is a Master degree programme offering a 4-years course.
In 1998 the Bulgarian Association of Family Therapy (BAFT) was founded. In 2000 it had 23 members (ibid). The goal of this association is to work for the introduction of training standards consistent with the standards of the EAP. The association participated at the preparation of the new Child Protection Law and the new Family Code. It maintains ties with other professional organizations like the social workers association, the child psychiatrists association etc. It is a candidate for membership at the European Association of Family Therapy.
Positive Psychotherapy
The method of Positive psychotherapy was created by Nosrat Peseschkian, a German medical doctor of Iranian origin. It is a version of short-term psychotherapy. Positive psychotherapy was introduced in Bulgaria by Arno Remers M.D., who is the referent for Eastern Europe of the International Center of Positive Psychotherapy (ICPP), seated in Wiesbaden, Germany. In the early 90-ies he organized a training course in the city of Varna.
The Society for Positive Psychotherapy in Bulgaria (SPPB) was founded in 1993; it is one of the largest national societies within the ICPP, second only to the Russian society (Boncheva, 2000). Among his 58 members are medical doctors, psychologists and schoolteachers.
The SPPB is organizing about 70 training courses each year leading to a national and international certificate (ibid.). These courses constitute a qualifying programme, consisting of ca. 280 hours of theory, practice, self-exploration and therapeutic practice. More than 100 participants a year acquire the certificate. In 2000 the SPBB had 52 professionals and 5 lecturers, certified in the field of positive psychotherapy.
Brief psychotherapy
Since 1992 in Bulgaria there has been a practice of brief therapy following the model of Steve de Shazer and Insoo Kim Berg called Solution Focused Therapy (SFT) (Anichkina, 2000). This model was first introduced to Bulgaria by Anton Karshutski M.D., a Bulgarian psychotherapist living in Sweden. In the mid-90ies Dr. Karshutski organized a two-year training course.
In 1994 the Society of Brief Therapists in Bulgaria (SBTB) was founded (s.a. Strahilov, 2000). In 2000 it had about 40 members. Its activities consist of organizing and conducting training seminars for students and professionals, creating a nationwide net of professionals applying the SFT, and maintaining ties to other helping professions. In 1995 some members of the SBTB were accepted members of the European Association of Brief Therapy. In 1997 the European Conference on Brief Therapy was organized in Sofia.
Further activities of the SBTB include training seminars on topics other than therapy, like “reteaming” (effective team work), the development of constructive communication, of competence management skills etc. (Strahilov, 2000).
Cognitive-Behavior Therapy
The first seminar on Cognitive-Behavior Therapy (CBT) in Bulgaria was held in 1998 by teachers from the UK (Lazarova, 2000). In Mai 1998 the Bulgarian Association of Cognitive- Behavior Therapy (BACBT) was founded. In 2000 it had 35 members. In Mai 1999 the South-European Regional Conference on CBT took place in Sofia. At this conference the accent was put on education: teachers from the UK and Denmark conducted 9 workshops.
Since 1998 the BACBT has been organizing training groups in CBT in collaboration with the University of Oxford in the UK. There is also an intervision group meeting once a month.
The BACBT is maintaining ties with the University of Oxford and with the World Association of Cognitive Therapy and has applied to become a group member of this association. The creation of a training module on CBT for psychiatrists and other helping professionals is in the offing.
Neo-Reichian Analytic Psychotherapy
The Neo-Reichian Analytic Psychotherapy was developed by the Swiss medical doctor, psychologist and anthropologist Valdo Bernasconi (Algafari, 2000). It is based on the theory of Wilhelm Reich and influenced by S.Freud, Al. Lowen, Fr. Perls and C.Rogers. Verbal as well as bodily interventions are applied.
The Bulgarian Neo-Reichian Society (BNRS) was founded in 1999. In 2000 it had 75 members; they have completed or are in training organized in collaboration between the Institute of Psychology and Psychotherapy in Düsseldorf, Germany, the Climent Ochridski University and the Medical University in Sofia and supported by the International Academy for the Development of Culture and Science. Their diplomas are consistent with the standards of the EAP (ibid).
The BNRS is a member of the International Neo-Reichian School (SIN). Head both of BNRS and SIN is Valdo Bernasconi. The BNRS is engaged in social programmes and in organizing seminars, supervisions and consultations concerning professional qualification.
Hypnosis
Beside the already mentioned Milton Erickson Institute of Sofia there is the Bulgarian Association of Hypnosis (BAH), which was founded in 1999. Its members apply hypnosis, suggestion and altered states of consciousness in their work (Nikolov, 2000). In 2000 BAH had 21 members, among them psychologists, medical doctors, dentists, specialists in speech disorders and students. Members of BAH can also be other professionals like specialists in sport, in law, in psychophysiology etc.
The BAH is organizing training courses in hypnosis and is planing to organize an international conference on hypnosis and hypnotherapy in Bulgaria in 2001.
Music Therapy
In 1994 Joseph Moreno from Merriville University in Saint Louis, USA, conducted a training course in music therapy in Sofia. In 1996 the Bulgarian Association of Music Therapy (BAMT) was founded. The BAMT has been organizing introductory seminars in music therapy and training group in the Bonny Method of Guided Imagery and Music (GIM) as well as a self-experience group for musicians and training groups in music therapy (Tomov, 2000). Teachers from various countries have been contributing to the seminars. The BAMT is a member of the British Association of Music Therapy, the European Confederation of Music Therapy and the World Association of Music Therapy.
The Bulgarian C.G.Jung Society
The Bulgarian C.G.Jung Society was organized in 1999 on the basis of the C.G. Jung text-reading seminar that functioned from 1992 to 1998. It is a voluntary non-profit association of professionals, who carry out therapeutic, teaching, research and other activities related to the analytical psychology of Carl G. Jung (Baichinska, 2001).
In May 2000, following the visit of the IAAP president Dr. Luigi Zoja, the Bulgarian C.G. Jung Society was given a status of a developing group of International Association of Analytical Psychology (IAAP). Financial support of IAAP opens up new possibilities for professional growth and development of the members. Recent activities of the Society included the following events:
1) a four-year program “C. G. Jung (an intercultural exchange: Sofia 2001-2004)” with the participation of Jungian analysts from Switzerland, Germany, France and Great Britain has started. Twice a year three-day workshops on different subjects of analytical psychology, complemented by one-day workshops led from certified Jungians that are held 3-4 times per year, take place;
2) a training program on sandplay therapy led by Jungian analyst has started in October, 2001;
3) a distribution and dissemination of Jung’s works;
4) a regular seminar work based on presentations of members of the Society (twice per month). The leading principle of the work of this seminar is an attempt to unite two approaches – experiential and theoretical. The theoretical ideas are first introduced on the experiential level – through psychodrama or active imagination, and then discussed on theoretical level.
Because of the limited financial possibilities the professional training has been slow and difficult. Two members of the Society are independent candidates in the IAAP Individual Membership Program; during the last 3 years they have been undergoing personal analysis and working under supervision.
Psychotherapeutic methods which exist only in Bulgaria
These include the methods of Krestnikoff, Cholakov and Shipkovensky that were mentioned in the first section of this article. I am not aware, however, of anyone still practicing any of these methods nowadays.
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4. The number of practicing psychotherapists
It is not possible to give even an approximate number of the psychotherapists who practice in Bulgaria. In the psychoanalytic modality there is only one trained psychoanalist and one psychotherapist trained in the Karen Horney approach (see above). Three or four of the members of the Group for Development of the Psychoanalytic Practice are doing analytically oriented therapy under supervision whithout having had proper training so far. There might be a number of others who work analytically oriented without having been trained themselves and without regular supervision by a psychoanalist. A small number of trainees in Lacanian psychoanalysis also work with patients. There are about 30 people who have completed training in psychodrama but probably less than one third of them do psychodrama with patients. In systemic family therapy, positive psychotherapy and neo-reichian therapy there are only a few individuals who have completed their full training.
As a very rough estimate, there are now less than 50 persons who have completed training in psychotherapy. The majority of them live in the capital city of Sofia, a small number live in Varna. Not all of them are practicing psychotherapy, at least not on a regular basis. There might be approximately the same number of people who are in training, or are about to start their training. It seems that the neo-reichian group of trainees is by far the most numerous.
There are, on the other hand, many people, who are psychologists, psychiatrists, medical doctors, social workers, and also many who are outside theses professions, who declare themselves psychotherapists and work with clients but have no training at all. A lot of the so called extrasensory healers, or parapsychologists, publish adds offering psychoanalysis and psychotherapy. Needless to say that noone of them never even thought of getting proper training.
5. Who is allowed to practice psychotherapy?
There are no regulations and no authority overseeing the practice of psychotherapy.
It is difficult to say what exactly the distribution of the basic professions among the psychotherapists looks like: those, who have full training, are mostly psychiatrists and psychologists. Among the candidates, it seems, the psychologists are taking the lead, followed by the psychiatrists and the social workers. However, we neither have exact figures on this subject so far, too.
6. Legal regulations on psychotherapy
There are no legal regulations on psychotherapy. Currently the National Umbrella Organization is working towards introducing such regulations (see below).
7. Payment
Because the majority of the people are poor and can’t afford psychotherapy the charges are very law, in the most cases between 5 and 15 BGL (1,96 BGL=1 Euro; the average salary in the country in 2001 was about 250 BGL). Recently the only Medical Insurance Company in the country decided to exclude psychotherapy from its reimbursement system, so those patients who want psychotherapy have to pay by themselves.
There are no direct investments in psychotherapy whatsoever.
8. Fields of psychotherapy
Psychotherapy is practiced mostly in private practice by single individuals. There is one counselling center connected to the Human Relations Institute (HRI) at the New Bulgarian University, but there are no psychotherapeutic wards at hospitals. Some projects run by the HRI, have established counselling centers of their own, e.g. a Center for the treatment of battered women, and a Center for schizophrenic patients. The National Drug Abuse Center is developing programmes to help drug addicts. These programmes include essential elements of psychotherapy. With the start of the health care system reform in 2000 some private psychiatric practices (so called “group practices”) as well as some outpatient clinics offer psychotherapeutic services. However, many of their therapists don`t have proper training or have no training at all. Some schools and social welfare institutions employ psychologists who try to do therapy; in the most cases these psychologists are not trained as psychotherapists.
A system of referring patients for psychotherapy does not exist in this country. Patients who find a psychotherapist are either referred by their psychiatrist, or by some psychologist or other helping professional, or by students in psychology, medicine etc. they know. There is, of course, a casual referring of a patient from one psychotherapist to another, but it happens not very often: there are not enough patients who can pay for psychotherapy, so there is a tendency to work with every patient who comes.
9. Organization of psychotherapy
The single umbrella organization of psychotherapy in Bulgaria is the Bulgarian Association of Psychotherapy and Psychological Counseling (BAPPC). It was founded in March 1993 and, in the beginning, only had individual members including all the psychotherapeutic trainees. At its annual meeting in June 2000 the BAPPC accepted 4 group members: the BSPGP, the BAFT, the SPPB and the SBTB. At present the association has about 150 members, among them 27 individual members.
In 1996 the BAPPC became a member of the European Association for Psychotherapy (EAP) and accepted the Strasbourg Declaration of 1990 defining psychotherapy as an independent profession. An application to be accepted as a National Umbrella Organization within the EAP is underway.
The principle task facing the association at this moment is to work for the introduction of legislation for the practice of psychotherapy. As mentioned above, in Bulgaria there are a lot of people, including psychiatrists and psychologists, who claim to be psychotherapists but have no training whatsoever. This circumstance is an obstacle to the regulation of payment for psychotherapy as well. On the other hand, with the introduction of training programmes in the different modalities the need for comparable standards for training becomes obvious. The BAPPC has appointed a working group to deal with this task. This group designed a project and managed to obtain financial support from the Geneva Initiative in Psychiatry. The goals of the project are to prepare a proposal to the Ministry of Health, the Ministry of Labour and Social Policy and the Ministry of Education containing the criteria for the training and practice of psychotherapy, the guidelines for establishing a National Register of Psychotherapists and the grandparenting procedures for awarding the European Certificate for Psychotherapy (the document introduced by the EAP). This project has been running for more than a year now. The first important results are that the BAPPC has adopted a policy towards introducing legislation for psychotherapy, so it can be a negotiating partner during the process of preparing such a legislation, and that in the New Health Act project a text concerning the practice of psychotherapy is indeed included. Although it is not exactly the one proposed by the Association, it can be a basis for further discussion, which now can take place during the Parlament debates on the Act.
10. Influence of psychotherapists
Some influential psychiatrists in Bulgaria are trained psychotherapists. For instance the current president and the secretary of the Bulgarian Psychiatric Association are trained psychotherapists. Psychotherapy is also gaining influence in universities; there is an increasing number of theoretical courses offers as well as even a training program in systemic family therapy. Within the social welfare system there is an increasing awareness of the necessity to take care of the psychological needs of the clients as well.
11. Psychotherapy journals
There aren`t any psychotherapy journals in Bulgaria. Occasionally articles on subjects related to psychotherapy are published in other periodicals like the Bulgarian Journal of Psychology, the journal Psychological Research, the Bulletin of the Bulgarian Psychiatric Association etc.
12. Significant publications
During the last 10 years there has been a boom of translations of scientific and popular books on psychotherapy starting with the works of Sigmund Freud and other classics and including many of the contemporary psychological best-sellers. Maybe because the practice of psychotherapy is in its very early stages, most of the scientific articles dealing with psychotherapy have an introductory character, i.e. they were written to present some method of psychotherapy.
13. Psychotherapy research
There aren`t any psychotherapy research institutions or groups, and there haven`t been any publications on research pertaining to psychotherapy. However, with the introduction of university programs of clinical psychology and psychotherapy, and with the gradual increase in psychotherapeuric activities there might be in the near future more possibilities to do research and more people interested. Recently the Institute of Psychology at the Bulgarian Academy of Sciences, a research institution, has shown interest in supporting research on psychotherapy.
Outlook
In my view, psychotherapy has to follow the path of becoming more professional. This requires the fulfillment of several tasks: the development of training programmes in all the main modalities, the introduction of legislation defining standards for the training and practice of psychotherapy, the inclusion of psychotherapy into the medical insurance system, the creation of possibilities of professional exchange, i.e. the scientific dialogue between the different modalities, a system for referring patients, and the connection of psychotherapeutic services to the ongoing psychiatric reform[‡].
These developments, of course, will have to experience the influence of a number of factors. On the positive side, for instance, are factors like the rapidly increasing number of training candidates and the support by foreign colleagues. On the negative side are factors like the overall poverty in the country, the relative paucity of experienced psychotherapists and the negative attitude towards psychological methods of treatment among some biologically oriented psychiatrists.
REFERENCES
1. Algafari M. (2000). The Bulgarian Neo-Reichian Society. In: Bulletin of the Bulgarian Psychiatric Association, No. 1. (in Bulgarian)
2. Anichkina A. (2000). Brief Psychotherapy. Ibid.
3. Atanassov N. (1997). The psychoanalytic movement in Bulgaria in the time between the World Wars. In: 25th Anniversary of the Institute of Psychology at the Bulgarian Academy of Sciences. Selected papers. Sofia: Marin Drinov Publishers. (in Bulgarian)
4. Baichinska K. (2001). Personal Communication.
5. Boncheva I. (2000). The Society for Positive Psychotherapy in Bulgaria (SPPB). Ibid.
6. CIA – the World Factbook. www.cia.gov
7. Danadzhiev S. (1912). Psychiatry in Bulgaria and in the neighbouring countries. In: Millenkov K. and C.Poppov (1983).
8. Dimitrova M. (2001). Personal communication.
9. Kamen G. (1992). The development of the Bulgarian psychoanalytic movement. Paper presented at Yale University, June 18-20.
10. Kinkel J. (1922). Zur Frage der psychologischen Grundlagen und des Ursprungs der Religion. Imago 8, No. 1-2.
11. Krestnikoff N. (1929). Die heilende Wirkung künstlich hervorgerufener Reproduktionen von pathogenen affektiven Erlebnissen. Arch. Psych. u. Nervenheilkunde, 88/3, S. 368-410.
12. Lazarova I. (2000). Cognitive-behavior therapy. In: Bulletin of the Bulgarian Psychiatric Association, No. 1.
13. Michova Z. (2000). Family therapy and the Bulgarian Association of Family Therapy (BAFT). Ibid.
14. Millenkov K. and C.Poppov (1983). The founders of Bulgarian psychiatry. Sofia: Medicina i Fiskultura Publishers. (in Bulgarian)
15. Nikolov M. (2000). Bulgarian Association of Hypnosis (BAH). In: Bulletin of the Bulgarian Psychiatric Association, No. 1.
16. Stanchev D. (2000). Bulgarian Society for Psychodrama and Group Psychotherapy (BSPGP). Ibid.
17. Strahilov B. (2000). The Society of Brief Psychotherapists in Bulgaria (SBPB). Ibid.
18. Tarashoeva G. (2000). Psychodrama and Group Psychotherapy. Ibid.
19. Tomov A. (2000). Bulgarian Association of Music Therapy (BAMT). Ibid.
20. Tomov T. and N. Atanassov (1995). Psychoanalysis in Bulgaria. In: Kutter P. (ed.). Psychoanalysis International: a Guide of Psychoanalysis througout the World. Stuttgart: frommann-holzboog.
21. Tögel C. (1983). Wilhelm Wundt und seine bulgarischen Schüler. Leipzig: Zeitschrift für Psychologie, B. 181, No. 1.
ADRESSES:
The Bulgarian Association of Psychotherapy and Psychological Counselling (BAPPC)
23, Solunska Str.
Sofia 1000, Bulgaria
Tel. +359 88 72 40 69
Fax +359 2 73 80 15
Email: n.atanassov@gmx.net
The Bulgarian Society for Psychodrama and Group Psychotherapy (BSPGP)
Chair: Georgi Antonov Dipl. Psych.
Tel. +359 88 34 37 17
+ 359 87 24 34 77
The Orpheus Psychodrama Centre
Director: Galabina Tarashoeva M.D.
Sofia 1000, P.O.Box 335
Tel. +359 88 20 99 29
Email: gtarashoeva@dir.bg
The Psychotherapy 2000 Foundation
45, Solunska Str.
Sofia 1000
Tel. +359 2 981 34 90
Email: genchev@geobiz.net
The Bulgarian Association of Family Therapy (BAFT)
Chair: Zlatka Michova Ph.D.
11, Shipchenski prochod str.
Block 228 A, App. 16
Tel. +359 2 70 98 21
Email: zmichova@olb.net
The Society of Brief Psychotherapists in Bulgaria (SBPB)
Contact: Boyan Strahilov Dipl. Psych.
Tel. +359 48 97 49 48
Email: boyans@bulnet.bg
The Society for Positive Psychotherapy in Bulgaria (SPPB)
Chair: Ivanka Boncheva Dipl. Psych.
5a, Polkovnik Sveshtarov Str.
Varna 9002, Bulgaria
Tel. +359 52 23 26 17
French-Bulgarian Training Project in Psychoanalytic Psychotherapy
Contact: Mimoza Dimitrova Dipl. Psych.
Tel. +359 2 74 90 39
+359 2 917 29 51
Bulgarian Association of Cognitive-Behavior Therapy (BACBT)
Chair: Petar Vassilev M.D.
Department of Psychiatry
Medical School of the Army
3, Georgi Sofijski Str.
Sofia 1606, Bulgaria
Tel. +359 2 917 22 27
Bulgarian Neo-Reichian Society (BNRS)
Contact: Madlen Algafari Dipl. Psych.
35, Parchevich Str.
Sofia 1000, Bulgaria
Tel. +359 2 987 72 75
Bulgarian Association of Hypnosis (BAH)
Chair: Mladen Nikolov Ph.D.
Pliska Str., Block 2 G, App. 61
Tel. +359 2 544 515
Bulgarian Association of Music Therapy (BAMT)
Chair: Irina Schlesinger Ph.D.
Tel. +359 2 962 21 37
The Bulgarian C.G. Jung Society
Contact: Krassimira Baichinska Ph.D.
Institute of Psychology
Bulgarian Academy of Sciences
Acad. Georgi Bonchev Str., Block 6
Sofia 1113, Bulgaria
Tel. +359 2 952 68 44
[*] Статия, публикувана в книгата: Pritz A. (Ed.) , 2002. „Globalized Psychotherapy“. Vienna: facultas.
[†] Later this year Dr. Kolev is expected to return to Bulgaria for a couple of years and to start analyzing Bulgarian candidates for psychoanalytic training.
[‡] The National Programme for reforming the Bulgarian psychiatry in the time between 2001 and 2006 is conceived as a part of the health system reform; it regards the old system of treating psychiatric patients in isolated hospitals as obsolete and inhumane. Its goals are to introduce a community based mental health system and to create the organizational basis, the procedures and regulations for the sustainable development of the mental health field in Bulgaria.