The current society is a different one
Conversation with Elisabeth Skale and Katharina Seifert of the Wiener Psychoanalytische Vereinigung.
Vienna, Austria, 13 October 2012.
David Arvidsson (DA): Please tell us about the Wiener Psychoanalytische Vereinigung (WPV): How many members do you have, what do you do?
Elisabeth Skale: At the moment our society has around 105 members. Besides that we have 90 candidates of which 30 or 40 are in active training.
To be a member you have to finish the training. The training includes a couple of moments which the International Psychoanalytical Association (IPA) strongly recommends to follow in a certain order. First of all you have to be in analysis yourself, four times a week. After at least one year in analysis you can start the theoretical seminars, that’s the second step. After or parallel to the theoretical seminars you can to begin the third moment; your training cases. You have to see two patients, each of them for two years four times a week with supervision once a week and it is strongly recommended to continue the training analysis throughout the training. Finally you give a paper on one of the cases where you describe it: how it went, how you theoretically understood it and what ideas it brought to your mind. This is to show that you can deal with the case, with actual clinical material and it’s theoretical implications.
The training is more or less the same in all IPA associations, but in total there are three models and they have some differences. The training standards are the main issue of the international association: the training has to be conducted in a certain way by the societies. It has been an important question since the beginning of the international association.
Emil Asbjörnsen (EA): How would you describe the situation for psychoanalysis in Vienna today? What are the main challenges?
Elisabeth Skale: Psychoanalysis has always consisted of two parts, on the one hand its therapeutic method and on the other hand its discourse. It has always been involved in a kind of struggle based on these two parts: a struggle for psychoanalysis as a therapeutic method and a struggle to keep up psychoanalytic topics in the main discourse in society. At the moment it seems like people are getting more interested in psychoanalysis again, and that concerns both these parts.
At the present we have two economists attending our training program. I think they mainly have a personal interest. I don’t think there is a psychoanalytic interest among economy students as a whole and I don’t think there is anything like a psychoanalytic movement in the university either. Still, there are a few people in different academic institutions who work with psychoanalytical theory, and that means something. We have also noticed that other sorts of training institutes, who for example focus more on consultancy and coaching, find support in psychoanalytical theories and technique. But it’s not like we are the main voice in the public conversation of Vienna, like we were between the Wars. No, we are far from that. At that time things were different, especially when it came to the question of discourse. For instance, the man who wrote the constitution of Austria, and internationally renown theoretician of Right, Hans Kelsen, gave a paper before the Vienna Psychoanalytic Society because he was concerned about social and sociopolitical problems and Freud’s view, especially in his mass-psychology and Totem and Tabu. Another example is the Vienna Circle, they were all interested in psychoanalysis, at least to some extent. Of course writers at that time were interested and a lot of different creative people wanted to talk to Freud about all sorts of things. The voice of psychoanalysis was definitely much louder. But today the opposite isn’t the case either: the psychoanalytical voice is far from dead, people still want to talk and they still want to listen.
To be honest, I don’t think we have a specific situation in Austria or Vienna, I think it’s more or less the same in Europe in general. Austria is very small, and especially the forced emigration during the Nazi-period destroyed the lively cultural and scientific discourse of the 1920:s and 1930:s. At the moment we don’t really have any proper newspapers. Since we speak German we read German newspapers and there is to my mind no specific Austrian culture. Of course we have writers whom we see as Austrian writers more than German. But in other topics we have more of a European or German discourse.
Rebecca Liedman (RL): What is the relation between psychoanalysis and the public care system in Austria?
Elisabeth Skale: Until June 2012 we had the best system in Europe for psychoanalysis, but we can see a change now. In Vienna it was more or less accepted to run a treatment of four sessions a week with a patient for four years, and even for a fifth year sometimes. The treatment was normally subsidised but in some cases the whole cost was paid for by the insurance system. This is changing now, because of lacking evidence when compared to the evidence the behavioural therapists present. Only in the last few years this has happened. We try to fight against it and we have been partially successful. But it’s evident you can see this sort of rapid change. It's hard to know what the future will look like.
Katharina Seifert: On this topic I think it’s important to say something about the general situation of psychotherapy in Austria. At the moment we have 23 different methods or schools of psychotherapy in the country which all are seen as equal to each other. In order to be allowed to work you have to be registered as a psychotherapist, but with so many different schools, especially in Vienna, you are confronted with an enormous amount of psychotherapies. [At present (2016) there are 32 training schools recognised by the Austrian ministry for health. – Ed.]
Elisabeth Skale: And this has a lot of advantages but it also has disadvantages. Every school has to present evidence to prove that their method is useful and effective. And of course the insurance companies are not willing to deal with the differences between the methods. They only see a large group of people who do the same thing [psychotherapy], some with one session a week for six months and then there are psychoanalysts who say they need five years and four times a week in order to be successful. They don’t understand the difference and sometimes they are not willing to deal properly with this complexity. We are trying to explain it to them, to make our voice heard, but this is not an easy task at the moment, at least not on the level of the health care system. In the medical academic discourse in the last 25 years psychoanalysis is described as “the former method”, maybe as a rebound to the popularity of psychoanalysis in psychiatry in the 1970:s and 1980:s. Nowadays even educated people are having a hard time to understand that it still takes years and several sessions a week in order to get sustaining psychic change. They are somehow shocked, thinking we are stuck in the last century while everything else has changed and has become so much faster. Also psychotherapy has to provide these quick fixes.
DA: What do you think that psychoanalysis need to do to meet this challenge of evidence based treatment and this "health-per-euro" way of thinking about psychotherapy?
Elisabeth Skale: We talk about this intensively in different meetings all over Europe and people take different positions in this matter. There are those who say that psychoanalysis, in its very nature, is different and therefore we cannot get into this discussion; that it’s impossible to convince people who are only interested of this type of research or efficacy studies and that it is better to not to be involved in this. I think the French did take this position somehow and they are therefore not dealing very much with this issue, while having a vivid cultural discourse. In Austria we are somewhat in the middle. We haven't done a study but we have people interested in doing one. We rely heavily on work done in Sweden, Finland and Germany where you find research projects that prove psychoanalysis therapeutically successful. But it’s a complicated issue and most of all we rely on clinical experience and other people’s clinical work. As soon as you design a study you also have to compromise the cure to some extent. That is necessary when you have to randomise and when you need therapists to follow manuals. It's very hard to do, or at least we are not trained or used to think of psychoanalysis in this manualised way.
There are controlled studies of long-term psychodynamic psychotherapy which is one or two sessions a week for a longer time, but when it comes to psychoanalysis we only have outcome studies up to now. These studies, on the other hand, show good results, but they are not designed in the format which is demanded now: randomised, double blind type of studies. But even if we don't have these sort of studies there are studies which show that even ten years after the psychoanalysis there are still changes going on, so former patients continue to improve. No other therapy, or study, can provide this kind of data. And this is an important difference, important for us and for psychoanalysis in general.
As psychoanalysts we try to initiate a process which is not finished even after the actual treatment has ended. It is a process that goes on internally and produce changes that makes the patient able to deal with difficulties on his own after the treatment. The debate which holds mainly economic arguments could use also this dynamic economic idea which is in favour of psychoanalysis. But it isn't heard at the moment.
Elin Elmrud (EE): If we leave the scientific and economic aspects for a while and turn to the patients: What are they asking for? Do you have many patients coming here asking specifically for psychoanalysis?
Elisabeth Skale: There are only a few patients who actually know about psychoanalysis and come here asking exactly for this. A larger group have a vague idea about what they need, an idea which often corresponds with psychoanalysis in some way even if they are not very familiar with it in detail. A lot of patients have already had other therapies and search for something as they have difficulties again. Of course there are people who know about it, but often they know about it from somebody else who has been in it or is in analysis at that moment. Often they see that people change in a certain way. They are mainly recommended by friends or by their family and find us more rarely on recommendation from a psychiatrist or other professionals. This is quite interesting.
EA: Is psychoanalysis possible for all of these patients? If not, what is needed in the patient for psychoanalysis to work?
Elisabeth Skale: It's an interesting question and hard to answer in general. You can only try to see a patient and try to initiate a process and see if the patient use the occasion to tell you something about himself. Many people have written about this question: What are the ingredients of psychoanalysis? Somebody asks to see you because he has a problem and you give him a certain time when he can meet a psychoanalyst. From the time he calls or writes , he doesn't know what it is he wants, he only knows that he needs something because he is suffering. You then give him a certain time and space from where he can start something inside himself. In the first interview, you have to listen carefully to what he is telling you, how he describes his main problem. What is he anxious about? Can he trust you or is he angry? Is he hopeful or desperate? There is a certain dynamic initiated in him, deriving from his inner dynamics, which will also show in the way he deals with the first contact. If the psychoanalyst is able to get in contact with this dynamic and communicate, this will suggest the person is suitable for a psychoanalysis.
Maybe it's a bit idealistic, but in this respect one can say that anybody who in someway is interested in himself and interested in what you have to say to him, is able to do psychoanalysis. Sometimes you can’t know this after the first session. But in general patients are very patient, they give you a second chance. If they have a feeling that you are able to get things right in principle, they provide you a second time with the same problem if you didn't grasp it the first time. This is relieving, at least for me. You don't have to catch everything on the first session. If you think of their situation; they have repeated and repeated something in order to understand it themselves and they are very willing to repeat it again in order for somebody else to understand and to help them.
EE: Since Freud founded your association, through the development of different schools – who of the post-Freudian theorists have been important to your society?
Elisabeth Skale: In our society different people have interest in different schools, and this can be very enriching but it can also be a problem. I think the society’s historical difficulties is playing a role in this matter as well. First of all because of the break of the society in 1938: this forceful, aggressive disruption. In between the Wars it was an intellectually very powerful society and up to 1938 nearly all the members were forced to emigrate. This was a major loss for the society and it never really overcame this disruption. For example: the society is still not very creative in producing its own ideas, it is not very active in writing. Sure there are members who write and who think, but not to any large extent. When it comes to this there is the biggest difference you can imagine between the former society and the current.
EA: A Swedish professor of the history of ideas , Sven Eric Liedman, recently said that modern society suffers of distrust, and along with this, he said, comes the desire for transparency. If this is the case one could think the situation would affect psychoanalysis very much, with its theory and method of transference for example, relying on the patient's trust in the knowledge of the psychoanalyst. Would you say there is a distrust in Austria today, a distrust of persons in positions of knowing something, for example professors or doctors?
Elisabeth Skale: Very much so. There is also a distrust in education and a distrust in knowledge and in most of the sciences. But in Austria it's difficult because there are a lot of complex political issues in the moment, which really needs transparence! So one is right to be a bit distrustful of politicians.
Katharina Seifert: I think that there is a negative attitude towards psychoanalysis linked to that, because you are not recognised as a kind of authority, which in a way you have to be. As you said, that's one of the basis of psychoanalysis: positive transference. And if this structure is disqualified a priori you have a very difficult situation. Today there are also a lot of self-help groups that say “we know everything ourselves and we don't need anyone to tell us anything”. This is a specific example of the more general attitude.
Elisabeth Skale: Even within psychoanalysis you have these kind of ideas coming up. For example, take the trend within inter-subjective and relational approaches towards equalising the positions between the analyst and analysand. In some way this idealisation of the equal relation is a denial of the difference between positions and roles. A form of lie in order to make something look like it's equal. You pretend that something is equal although it's not. There is, at least not for me, no problem if things aren't equal in this respect.
EA: How is the situation for psychoanalysis within psychiatric care in Austria? Can you speak about psychoanalysis? Does it inspire people working in psychiatry? How is the environment?
Elisabeth Skale: I was in training in the eighties, maybe the situation was different then, but I think it depends on where you are. There are psychiatric clinics where psychoanalysts, or people who are in training to be psychoanalysts, work. Then you have university clinics for example, where I don’t think psychoanalytic ideas are very present. Even if there are young colleagues who are interested and who are in training at the Society, in general, in "proper" psychiatry, it’s not something you value or talk about.
EA: Is it taboo to be interested in psychoanalysis?
Elisabeth Skale: More or less yes. There are some analysts working in the psychiatry and people know they are analysts. And I don’t think anyone has got any problem with that. But, altogether, with diagnostic manuals like the DSM-IV, psychoanalysis is wiped out as they only focus on symptoms and syndromes and how they are formed and defined by biological and pharmacological effects. There is nearly no idea about how things are combined on an intra-psychological and social level. For example when one medical substance diminishes certain anxieties and compulsions, a “syndrome” with these symptoms is constructed, which can be treated by this medication. It’s a circular reasoning which leaves no space for psychodynamic thinking. But I think it's a problem for psychiatrists as well, or it is becoming a problem, because they only have these symptoms in mind, lacking a more comprehensive idea of the person.
EE: An interpretation?
Elisabeth Skale: Yes, or an understanding. I think this points to why you need some kind of nosology; it’s to get hold of the person. You don’t only have symptoms, they also relate to some kind of logical structure, like neurosis or psychosis for example, at least this is what psychoanalysts are convinced of. The symptoms are easier to understand if you have an idea of how they come about. I find that, or at least I hope that, this extreme statistical thinking (which medication works best for which “syndrome”) will slowly generate a lack of something in psychiatrists. We are very glad to see young male psychiatrists applying for training. This is important because since decades there is a tendency in psychotherapeutic education and in social professions in general that these professions have become a woman’s business, which is very negative for a profession in the way status works in relation to sex and power. And in this way it’s also a bad sign for psychoanalysis. I think it's very important to raise this question: Why is this profession not interesting for men anymore? Is it a too motherly or caring profession? As if it's not about intellectual ideas anymore.
EE: You mentioned before the interview that you also have public lectures?
Elisabeth Skale: Yes, two times a year members of the society talk about psychoanalysis. The topics vary every year. We started with Freud’s case histories and next year we will talk about dreams and about what psychoanalysis really is. A lot of people show up, a lot of candidates and also other psychotherapists, but unfortunately not the real public.
We also started some cooperations. Next year we will have a cooperation with the institute of sociology about this new phenomena of a social command to “wellbeing”. We will also discuss what it means to feel unwell, if it can be understood as neurotic or if it’s a question of a burn-out syndrome.
EA: In Gothenburg it sometimes seem difficult to discuss psychoanalytic ideas in certain academic environments, like the institution for psychology for example. On the other hand there seem to be a more welcoming approach within the sciences of humanities. How is the situation in Vienna?
Elisabeth Skale: It's the same here. The institute for psychology is definitely not interested in psychoanalysis.
DA: What about other parts of the university, like history and literary criticism for example?
Elisabeth Skale: Historians are interested and also people from the applied arts. We are even thinking of the possibility to start a master of psychoanalysis together with the University of Applied Arts. In that case we would have courses both here and at the university. If this becomes reality we could have a master in psychoanalysis. We have ongoing discussions about how to do this, practically and financially, and if it works out I think it would be very good. It would be a step towards getting academic students more interested in psychoanalysis and to make it possible for them to learn and write about psychoanalytical theory without having to engage in practical training.
Tormod Johansen (TJ): One last question. Being a part of the International Psychoanalytical Association (IPA) and at the same time being the original association, does that mean anything within the IPA?
Elisabeth Skale: No. And I think this is another aspect of the destruction during the Nazi time. The Vienna society lost a lot of its intellectual power.
Katharina Seifert: But historically, the emigrants did a lot. They founded a lot of foreign institutes across the United States for example. The remains live on at other places one could say.
Elisabeth Skale: But the current society is a different one than the former, only the name remained.
Elisabeth Skale (MD) is a psychiatrist, member and training analyst at the Vienna Psychoanalytic Society (WPV). President of the Society 2009–2013.
Katharina Seifert is a psychologist, member and lecturer at the training programme of the Vienna Psychoanalytic Society (WPV).