Switzerland
Switzerland is a complex country: 26 educational systems in a territory of six million people. Unheard of! To speak about ‘psychotherapy’ or ‘psychoanalysis’ in Switzerland is, for similar reasons, also a nonsense. The cultural and socio-economic differences in the different parts of the country—all these parts are very eager to maintain their autonomy—works in the direction of great diversity. In rural, conservative, traditionalist cantons we find a lack of any significant psychotherapy. In Geneva the density of the therapeuts is comparable to that of Manhattan: on the shores of the great ‘Lake of Geneva’ there are some 150 medical psychiatrists and psychotherapists working and about the same number—if not more—of psychologists working in the field of mental health for some 400,000 people. In Zürich we can find at least four major analytic schools (Freudians, Marxo-Freudians, Jungians and Existentialists). In Geneva there is hardly any other tendency than a Freudian analysis out of all possible orientations, like Lacanian, Lagachian, British object-related people, Latino-American-Kleinian, British-Kleinian amongst many others, not to speak of non-analytical orientations. The only ones you will not hear about, at least until now, are New Age therapists. In Lausanne—a very different cultural environment, petty-bourgeois in a heavily agricultural canton—everybody is obedient and orthodox. But the orthodoxy of Lausanne is neither that of Geneva nor Bern nor Zürich.
Are these people crazy? I don’t think that they are more or less so than in other places, but the small dimensions—the miniature kaleidoscope of the country’s cultural diversity reflecting in a little ‘summary’ on such a small territory—makes it striking and caricatural. But the situation is certainly analogous to many other places in the world.
The Swiss situation also reflects that which predominates in our ‘Western’ civilisation in this domain—a polarisation of medical and non-medical psychotherapy, a fierce competition for material resources and for the money of the health insurance companies (Krankenkasssen, caisses maladies) on which the Swiss health system is based and a mediocre training in the universities, medical or psychology faculties, and a somewhat better clinical postgraduate training in private societies—as it seems to me in many other places (the majority) throughout the world.
The future will certainly be determined in part by the outcome of the power struggle which is already in progress between the medical establishment, the health insurance people, the non-medical psychotherapists (the majority of them psychologists, some nurses and social assistants, but also theologians and sociologists) and the need of the people for psychotherapists.
To begin with the latter, there can be no doubt that in the last decades this need has changed a lot: in the 1950s and 1960s analytic psychotherapies were fashionable. Nowadays, brief, (apparently) cost-effective ones are far more desirable. Following a ruling by the Federal Supreme Court for Insurance, it is only recently that the health system has taken over the financial responsibility for a limited amount of hours of psychoanalysis. So there are less material limitations than there were in the 1950s or 1960s and the apparent need for psychoanalysis is decreasing, but for psychotherapies and drug treatments the need is increasing. These are now often offered by general practitioners of medicine, family doctors and interns, so the circle of the care providers is continuously enlarging. All this is—as I have underlined already—not very different from the situation in other countries in the western hemisphere, except for the situation of non-medical psychotherapists, which shows bigger major local diversities: all the major cantons have their own legislation on this subject (although a federal law is promised to overrule them sometime in the future). At present, for example, in the canton of Basle, the conditions for practising psychotherapy for non-medical professionals are strictly determined. In others, like Geneva, any legislation on this subject is still absent. In some areas health insurance covers the expenses of a psychotherapy (in general to around 80%) by a non-medical practitioner if the necessity is confirmed by a medical doctor, usually a psychiatrist. In other areas no such arrangement is practised or only in a very limited number of cases (e.g. for a non-medical psychotherapist working in the same office as the doctor-psychiatrist prescribing the treatment).
The non-medical psychologists are pressing hard for a more important share of the market, the health insurers are diminishing the insurance money going into this field. The medical establishment is divided: the new drug therapies appear to make some long-term psychotherapeutic treatment (especially for very ill persons, like psychotics) obsolete or only at least a very restricted validity as ‘adjunct’ therapy. Some medical decision makers would be prepared to work with a majority of non-medical psychotherapists as the training of medical psychotherapists appears too costly (i.e. non-efficient) to them. Like physical therapies—massage, rehabilitation psychotherapy could be practised more economically by people trained for it—without necessarily having an MD and a long psychiatric training.
Perhaps most interesting is the shift in the place of psychoanalysis. Although psychoanalysis has never had this dominant (or quasi-exclusive) place in Europe—or in Great Britain, Germany, France, nor even in Switzerland—as it had in the United States or Canada in the 1940s to 1960s, its impact was nevertheless important. Now we observe everywhere an atmosphere of pluralism of paradigms and even change of paradigms. Neurobiology has taken an important place in research and psychopharmacology in treatments—psychoanalysis and treatments inspired by it no longer has a monopoly. Psychoanalysis, in turn, has inspired social sciences and humanities. In French-speaking countries in general, the influence of Lacan and of thinkers more or less influenced by him is paramount—but not in medicine or psychotherapy.
Psychoanalysis becomes an instrument of ‘meditation’ with more than just medical aims—primarily a training instrument for people who have chosen to work in the field of mental health, education or in cultural fields like history, literary criticism and so forth. Psychoanalytically inspired theories of human development are nevertheless highly appreciated and their impact on paediatrics and paedopsychiatry remains important.
A new federal law concerning the health care system was introduced in Switzerland in January 1996. The full effect has still to be evaluated. The system implies a much stricter control of medical personnel by HMO (Health Maintenance Organization) people, by managed care supervisors, by departments of the State and by the insurance companies. This reform was imposed by a socialist minister and generally well accepted by people who hoped for a diminution of their health care budget. Initially, however, the changes have brought severe turmoil and not the expected diminution of the expenses. How it will work out cannot be foreseen for the moment and the number of people who regret all these changes and think that the old system was not so bad is increasing.
These few examples may give some insight into the future of psychotherapy in Switzerland—and not only in Switzerland. Moving away from the medical field, psychoanalysis may stay with us as a tool for meditation about ourselves in a contemporary modern or postmodern intellectual framework. Simple—behaviouristic, cognitive—and brief forms may stay in the medical field, practised more by psychologists than in the past. Medical insurance may restrict itself more and more exclusively to these later forms of therapy. Is that all for the good of the people? Maybe we can tell in a few decades. We hope that it will not be too late.
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