Creating a medical speciality: psychotherapy in the post-war Soviet healthcare system

INTRODUCTION

Defining psychotherapy is a difficult task. The origins of the term can be traced back to late nineteenth-century Europe, where it was used to refer to therapies based on hypnosis and suggestion. In the twentieth century these methods were surpassed by psychoanalysis, which for a time became the dominating psychotherapeutic treatment, exerting the greatest influence on how psychotherapy was viewed and imagined in Western European and American society [1, 2]. However, over the course of the century psychotherapy came to encompass a wide variety of approaches, espousing different views on such matters as the causes of disorders of the human mind, the relationship between the patient or client and the therapist, and the aims of psychotherapeutic treatment. For that reason, it is more helpful to speak of psychotherapies rather than psychotherapy, and it should be remembered that upon closer scrutiny its various forms might not have much in common.
This paper focuses on psychotherapy that existed and gradually grew in popularity in the post-war Soviet Union. While its main methods were not Soviet, or even Russian, in origin, the shape of this discipline in the USSR differed significantly from the one that it took in post-war Western Europe or the USA. This was a result of changes that took place in the country after the October Revolution. Initially the development of psychotherapy in Russia and the USSR followed essentially the same path as in other European countries, beginning with therapies based on hypnosis and suggestion, followed by a great wave of enthusiasm for psychoanalysis in the 1910s and 1920s. In the first years after the revolution Freud’s method enjoyed great popularity and even attracted the support of some figures in the new Bolshevik regime, most notably Leon Trotsky. However, it soon became one of the intellectual trends that came under increasing criticism at the onset of Stalinism, and it virtually disappeared by the end of the 1920s [3, 4]. In its absence other psychotherapeutic methods, which in Western Europe were surpassed by psychoanalysis, flourished. These included treatment through hypnosis and suggestion, rational psychotherapy developed by a Swiss physician Paul Dubois, and different methods of autosuggestion. Over the following decades, all of these methods were further developed by Soviet practitioners of psychotherapy1, who sought to improve their practice and better understand their physiological mechanisms.
This paper tells the story of Soviet psychotherapists’ post-war efforts to improve the status of their discipline and to establish it as a standard treatment within the Soviet healthcare system. The theory and practice of psychotherapy in the post-war Soviet Union has largely been absent from English-language scholarship, with the exception of several contemporaneous accounts by western therapists who visited the country [6-8] and mentions in a few studies by contemporary scholars [9-12]. This paper aims to draw attention to the fact that psychotherapy was not only present in the post-war Soviet Union but was actually growing in popularity and prominence. The steps towards this process began in the final decade of Stalin’s rule, and from the mid-1950s calls for inclusion of psychotherapeutic treatments into the practice of hospitals, polyclinics, and sanatoria became increasingly more pronounced, particularly after the foundation of the first psychotherapy course at the Ukrainian Institute for the Advanced Training of Physicians in Kharkov in 19582. This paper looks at how Soviet psychotherapists transformed psychotherapy from a treatment practiced chiefly by enthusiasts at a limited number of institutions into one that was promoted by the Ministry of Health Protection (Minzdrav) and systematically introduced into the Soviet healthcare system.
In his seminal monograph tracing how professions compete for jurisdiction over fields of work and expertise, Andrew Abbott [13] argued that American psychotherapy established itself as a profession through winning jurisdiction over the so-called “personal problems” from the clergy. At first glance it appears that in the post-war Soviet Union psychotherapy was also emerging as a distinct profession; its promoters enthusiastically argued for its importance and identified areas in which they could make a unique contribution. Following Abbott’s terminology, this article asks how psychotherapists fought for and won jurisdiction over certain fields of expertise and what these fields of expertise were. However, a closer examination of actions and aspirations of Soviet psychotherapists reveals that establishment of psychotherapy within the Soviet healthcare system in the post-war decades should not be seen as the emergence of a new profession, as conceptualised by Abbott. While Soviet psychotherapists certainly attempted to win a jurisdiction over certain aspects of treatment and aspired to be recognised as experts on such issues as, for example, proper communication between medical personnel and patients [14], they did not seek to become a distinct profession but rather to secure a place for themselves and their methods within the already established profession of medicine.
The goal of Soviet psychotherapists was not so much to claim jurisdiction over a distinct field but to show that the issues that they dealt with and the methods that they used belonged under the jurisdiction of medicine. They stressed the unique skills that they offered in order to demonstrate the usefulness of psychotherapy; however, they also put a lot of effort into underlining the similarities of its methods to the treatments already perceived as obvious tools of medicine. Soviet psychotherapy was conceptualised and promoted as just another medical procedure that should be placed alongside “drugs, the surgeon’s scalpel, or physiotherapeutic procedures” [15].
This paper focuses on the efforts undertaken by psychotherapists to have their knowledge recognised as another part of strictly medical knowledge, developed and applied by scientists and physicians like any other. It traces the road to the addition of psychotherapy to the list of medical specialities in 1985 and examines problems that hindered this process along the way, contributing to the fact that while on paper psychotherapy became a part of medicine with status equal to its other branches, what its practitioners could accomplish in practice came short of their plans and hopes.

MATERIAL AND METHODS

This historical study was conducted using both archival sources and psychotherapeutic literature published in the post-war Soviet Union. The discourse analysis of published psychotherapeutic materials, including monographs, articles, and collections of conference papers, offered insight into how Soviet psychotherapists perceived themselves and their discipline, what they regarded as obstacles to its development, and how they attempted to overcome them. These texts, often aimed at other physicians and sometimes at the general public, are a good source for determining strategies used in order to improve the status of psychotherapy and convince the medical profession as well as the patients of its effectiveness and scientific nature.
The archival materials accessed at the State Archive of the Russian Federation and the Central State Archive of the City of Moscow consisted of sources relating to Minzdrav decrees on psychotherapy and annual reports from medical institutions. They provided data on the official state plans for the development of the discipline as well as on the practice of establishing psychotherapy offices within the Soviet healthcare system. Collections of papers given by Soviet psychotherapists at their conferences also proved to be a valuable source on the reality of practicing psychotherapy in the Soviet Union. In addition to discussions of theoretical and methodological issues and research conducted in the field of psychotherapy, these collections include papers reporting on successes and failures of establishing psychotherapy at hospitals, sanatoria, and polyclinics and on obstacles to the development and popularisation of the discipline. As such, they were important for identifying the main problems that hindered the growth of psychotherapy.

DISCUSSION

The road to the recognition of psychotherapy as a medical speciality was not smooth, and the problems that hindered it along the way led to the situation where on paper psychotherapy became a part of medicine with status equal to its other branches; however, what its practitioners could accomplish in practice fell significantly short of their plans and hopes. These problems can be divided into two broad categories. First of all were obstacles relating to the perception of psychotherapy, which stood in the way of its rise in status and called into question its medical and scientific nature. Secondly were those that hindered the actual practice of psychotherapy at medical institutions and stemmed from limited availability of financial and other resources as well as personnel. The analysis of the development of Soviet psychotherapy shows that by 1985 the first set of problems, although by no means entirely eradicated, was overcome to an extent sufficient to secure the status desired by its practitioners. However, the second set, despite certain improvements, was still firmly in place and was ultimately responsible for the psychotherapists’ inability to achieve many of their ambitious plans.

JUST ANOTHER MEDICAL PROCEDURE

One of the main challenges faced by Soviet psychotherapists was prejudice or a dismissive attitude towards their methods of treatment. They frequently lamented the lack of knowledge about their discipline within the medical community. In his influential monograph Konstantin Platonov [16] expressed the need for exposing colleagues in the medical profession to evidence of the efficacy of psychotherapy because physicians of all specialities, including psychiatry, doubted it due to their inadequate knowledge. Other promoters of psychotherapy also openly stated that they wrote their monographs to combat ignorance within the medical community and on some occasions also offered stories of sceptical colleagues who changed their minds about psychotherapy after witnessing its positive impact at their institution [17-19]. Some also drew attention to the need to improve understanding of what psychotherapy was among the patients, who did not treat its methods seriously, thought that therapy that relied on words was “beneath their dignity”, and believed that if they could be cured by words, they were not truly ill [15, 19].
These remarks and concerns suggest that prejudice against psychotherapy was widespread enough to be considered an important obstacle by physicians who wanted to promote it: an obstacle that was caused by misconceptions held about psychotherapy by Soviet physicians and that could be removed simply by clarifying what Soviet psychotherapy was and providing examples of its efficacy. These clarifications took the form of denouncing two things with which psychotherapy was associated and which damaged its standing as a scientifically substantiated discipline: mysticism and miraculous healings on the one hand and psychoanalysis on the other. At the same time, the scientific nature of psychotherapy was asserted through explanations of its physiological mechanisms, based largely on the ideas developed by Ivan Pavlov in the 1930s.
The association with mysticism and the occult was attached to hypnotic suggestion: one of the most popular methods of psychotherapy used in the Soviet Union. It was naturally opposed by psychotherapists, who combatted it by explaining what they believed to be physiological mechanisms of hypnosis and claiming that this method of exerting psychotherapeutic influence had previously been usurped by various charlatans but that its rightful place was within the realm of science and medicine3. Interestingly, they did not deny the reality of some of the miraculous healings. Vladimir Rozhnov, the head of the School of Psychotherapy at the Central Order of Lenin Institute for the Advanced Training of Physicians in Moscow since 1966, wrote that the myth of such healings would not have persisted for so long had there not been “some real cases of freeing the sick from their ailments” [21]. Following Pavlov’s ideas, Soviet psychotherapists explained hypnosis as a state akin to sleep, induced by prolonged monotonous stimulation of the nervous system. Such a state often increased the effectiveness of verbal suggestion, which acted upon the human nervous system, and through it could exert an influence over the entire organism4. Rozhnov and Rozhnova [21] explained that in the past these mechanisms were accidentally or cynically used by various charlatans and religious figures but that now they could be reclaimed by medicine and consciously, purposefully implemented in the clinic.
Another (more pervasive) obstacle to the status of Soviet psychotherapy was an association with psychoanalysis in particular and with various methods of psychotherapy deemed to subscribe to an “idealist” and unscientific worldview in general. Psychoanalysis remained in disfavour after Stalin’s death, and various criticisms that were raised against it, such as ignoring the biological aspects of human nature, treating the mind as an entity distinct from matter, and more broadly its “reactionary” nature, could by association be extended to other forms of psychotherapy. Aware of their discipline’s vulnerability to such accusations, Soviet psychotherapists distanced themselves from psychoanalysis and other forms of psychotherapy practiced in Western countries, arguing that they were not only pursuing a very different approach to psychotherapy but also that they were actually working to repair the damage done to the discipline by Freud and the dualist view of human mind and body.
Platonov [16] wrote: “The main reason impeding the scientific substantiation of psychotherapy in the past was the dualistic view of the nature of the human personality prevalent at that time. (…) It was only with the further development of Pavlov’s physiological teachings on the higher nervous activity that psychotherapy entered on a new path which has made possible the materialistic understanding of the underlying mechanisms and which has opened new and extensive practical possibilities. Pavlovian physiology has created a physiological basis and has discovered the mechanisms of higher nervous activity permitting of an understanding of the essence of psychotherapy and its proper application”.
A similar position was expressed by Zavilianskii [23] of the Bogomolets Kiev Medical Institute, who argued that “the field of psychotherapy was always susceptible to idealist interpretations” and that before Pavolv analysis of mechanisms of therapeutic influence was indeed based on “introspection and speculation” but his research provided psychotherapy with a physiological basis, allowing it to become a properly scientific discipline.
The reliance on physiology as a legitimising strategy for psychotherapy meant that promoters of psychotherapy wrote about it differently than did their colleagues in Western Europe or North America. Psychotherapeutic publications talked about the cerebral cortex, conditional reflexes, stimuli, and functioning of the nervous system much more than they did about patients’ experiences, feelings, or personality. Platonov’s [16] seminal monograph, reprinted in the 1950s and regularly referenced throughout the following decades by psychotherapists around the Soviet Union, was titled Word as a Physiological and Therapeutic Factor and dedicated largely to explaining the physiological mechanisms behind psychotherapeutic influence. Defining psychotherapy, another one of its enthusiastic promoters, Mark Lebedinskii [24], stated that its main task was to “regulate the disturbed dynamics of the neural processes in the brain and thereby to restore the balance of functions in the whole organism”. The physiological language used to describe Soviet psychotherapy and the focus of its legitimising strategies highlight that, unlike American psychotherapists described by Abbott [13], Soviet psychotherapists sought recognition not as a new profession but as scientists and physicians, consistently presenting themselves as dealing with the same field as other members of the medical community: the mechanisms and diseases of the human organism.
The efforts to establish the status of psychotherapy as a part of medicine were, on the whole, successful. While prejudice and doubts against it were not entirely eradicated, psychotherapy became gradually integrated into the professional institutions and medical education facilities and included in the plans for the development of Soviet healthcare. As early as in 1962 the All-Union Scientific Society of Neuropathologists and Psychiatrists founded a section dedicated to psychotherapy, to help spread knowledge about psychotherapeutic methods among medical professionals. In 1975 Minzdrav prepared a programme for introducing psychotherapy into the practice of medical institutions in all Soviet republics [25], and 10 years later psychotherapy and the title of physician-psychotherapist were officially added to the list of medical specialities recognised in the USSR. Minzdrav also drafted further plans to integrate and popularise psychotherapy in the Soviet healthcare system [26].

LIMITED SUCCESS

The efforts to establish psychotherapy in the healthcare system of the post-war Soviet Union certainly were effective. In a few decades the discipline went from a rare treatment associated with charlatans and unscientific assumptions to a medical speciality introduced by Minzdrav into more and more hospitals and polyclinics. However, this success was also significantly limited due to the second set of problems that hindered the establishment of psychotherapy as a new medical speciality: financial issues, limited availability of resources and of personnel, as well as the fact that other needs of the healthcare system tended to take priority.
Psychotherapy was being introduced into a struggling, underfunded system of Soviet healthcare, plagued by shortages of staff, inadequate training, and insufficient supply of medical equipment and drugs [27, 28]. Gaining more status would not guarantee the resources needed to establish a proper, well-developed network of psychotherapeutic services in the situation where more established medical specialities lacked funds to procure necessary equipment and sometimes could not run enough of the necessary medical tests [29]. Consequently, the steps made towards introducing psychotherapy into the Soviet healthcare system were rather limited, given the scale and population of the USSR.
This was certainly the case with the 1975 Minzdrav decree “On measures towards improving psychotherapeutic care”, which initiated the creation of psychotherapy offices in all Soviet republics [25]. While it was certainly am important step towards increasing the availability of psychotherapeutic services, a closer look at the decree reveals that in some cases only one or two offices were to be opened for an entire republic. Similarly, the system that was in place for training psychotherapists5 also had a limited capacity, and as the discipline grew in status and popularity, voices could be heard that some physicians who wished to incorporate psychotherapy into their practice were unable to do so due to the lack of access to adequate training [30].
What is more, at the institutions where psychotherapeutic offices were created, they struggled with a lack of appropriate space and resources and, particularly before the decree of 1975, often functioned thanks to the enthusiasm and commitment of staff who undertook work as psychotherapists in addition to their normal duties. For example, in the mid-1960s 15 health resort institutions in Crimea offered psychotherapy as a treatment, but only two of the physicians who performed it had been freed from other duties and employed as psychotherapists. All the others offered psychotherapy in their free time and of their own initiative [31]. The process of introducing psychotherapy at the polyclinic by the Krasnodar Cotton Mill Hospital provides a good illustration of the difficulties faced by its enthusiasts and promoters. In the 1960s neurologists working at the polyclinic began to include elements of psychotherapy into patients’ visits to the neurological office. Usually they limited themselves to simple techniques that calmed patients and restored their hope for recovery; however, occasionally they disregarded the time limit for a visit and conduced hypnotherapy. In 1970 they managed to get permission to dedicate 1-2 hours three times a week to psychotherapeutic treatment; however, due to the lack of an appropriate room they could not perform group therapy6 and consequently could see only a very limited number of patients. Three years later the provision of psychotherapy was extended to 2-3 hours a day and a room for group therapy was finally provided in 1975 [34]. The neurologists in Krasnodar were also lucky in how much support they received, as in the mid-1970s their colleagues in the nearby Novorossiysk or Armavir were still working solely of their own initiative, in addition to their normal duties [35].
In the 1970s it was still common that institutions that offered psychotherapy did not employ a single psychotherapist because they did not have the financial resources to create an additional job position. Many institutions, just like the neurologists in Krasnodar, struggled to find a space in which group psychotherapy could be conducted and had to either work within the hours during which rooms used for other types of therapy were empty or significantly limit the number of patients that could receive any type of psychotherapeutic support [36-38]. What is more, even if an institution created job positions for the psychotherapy office and provided an appropriate space for its treatments, the limited number of spaces on appropriate courses and the needs of other medical departments could become an obstacle. For example, in 1975 the psychotherapist employed at the Karachi Lake health resort in Novosibirsk region became unable to continue working and it took three years before a new physician from the institution could attend the appropriate training in Kharkov [37, 39]. What is more, due to the shortage of staff, soon after completing his training he was redirected back to his old neurology department and remained unable to fully commit to working as a psychotherapist [39], which shows that even when the value of psychotherapeutic treatment was recognised, the needs of other medical specialities still took priority.

CONCLUSIONS

Soviet psychotherapists envisioned a broad range of applications for their discipline. They aspired not only to treat the conditions they usually focused on, such as neuroses, functional disorders, or addictions, but also to establish their methods as a standard auxiliary treatment for a variety of organic diseases and as a prophylactic measure preventing development of iatrogenic illnesses in patients and mental health conditions in the healthy population [14, 16, 40]. Individual psychotherapists conducted research in this area and extended the application of psychotherapeutic methods within their institutions. However, the realities of the Soviet healthcare system meant that the majority of efforts to promote psychotherapy focused first of all on proving to the medical community and the healthcare authorities that it was a scientifically substantiated medical treatment and secondly, increasing the availability of basic psychotherapeutic treatments throughout the Soviet Union.
These efforts were certainly not unsuccessful. The very fact that Minzdrav became involved in establishing psychotherapy at polyclinics throughout the Soviet Union was a victory for psychotherapists who worked to promote their discipline and to secure state support for its expansion. Its position significantly changed between the first post-war decade and the mid-1980s. At the start of the post-war period it existed at the margins of Soviet medicine, practised by largely self-taught physicians and often dismissed by both other medical professionals and patients. In the following years knowledge about psychotherapeutic methods and what was believed to be their physiological mechanisms spread around the medical community thanks to numerous publications on the topic and physicians who, of their own initiative, worked to introduce psychotherapy at their institutions. By the mid-1980s these efforts resulted in the addition of psychotherapy to the list of medical specialities, and in some state support for its growth as a discipline. This improvement in both status and availability of psychotherapy should not be overlooked; however, it must also be noted that financial support for its development remained limited and other needs of the healthcare system continued to be given higher priority. The Minzdrav [25, 26] decrees were important steps towards improving psychotherapeutic coverage, but they were also small steps, given the scale and population of the Soviet Union. Consequently, although status of psychotherapy improved in the eyes of the medical community and healthcare authorities, in practice it remained largely concentrated in urban areas or health resorts, and thus not available to large sections of the population.
Not long after the 1985 Minzdrav decree recognising psychotherapy as a medical speciality, the shape of the discipline began to change. First, amid changes occurring in the country under Gorbachev, other approaches to psychotherapy began to enter the Soviet Union, bringing with them different views on what is was or should be as a discipline. Then, in the early post-Soviet years, Russian physicians lost their “monopoly on psychotherapy” as psychologists became free to offer psychotherapeutic services [41, 42]. This development somewhat mirrors the history of psychotherapy in the United States, where a few decades earlier the profession faced competition from psychologists and finally conceded its jurisdiction over “personal problems” [13]. Nevertheless, the history of Soviet psychotherapists’ endeavours to be a part of the medical profession was not inconsequential, and some of their theoretical approaches and methods continue to be used in Russia; referred to as “clinical psychotherapy”, they are still the domain of physicians and exist as a distinct strand of the discipline, alongside a variety of psychotherapeutic services offered by people lacking medical training [10, 41-43]. Although efforts undertaken to promote psychotherapy in the post-war Soviet Union were limited by the financial and personnel constrains of the country’s healthcare system, they succeeded in establishing a new medical speciality and left a mark on the psychotherapeutic landscape of modern Russia.

DISCLOSURE

The author reports no conflict of interest.

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1Until the creation of a medical speciality in psychotherapy in 1985, psychotherapy in the USSR was most often practiced by psychiatrists and neurologists. In contrast to the United States, where in the post-war years growing demand led to psychotherapeutic treatments being offered privately by psychologists and social workers [5], in the USSR psychotherapy remained the domain of state-employed physicians and was presented as a strictly medical procedure.
2The course was the first step towards the foundation of the entire School of Psychotherapy, Psychoprophylaxis, and Mental Hygiene at the same institute in 1962.
3The attempts to reclaim hypnosis as a scientific, not mystical, practice were made by Russian physicians as early as in the nineteenth century and around the October Revolution [19, 20].
4For more on Pavlov’s and Soviet psychotherapists’ views of physiological mechanisms behind hypnotic suggestion see [16] and [22].
5The training in psychotherapy took place at three Institutes for the Advanced Training of Physicians: in Kharkov from 1958, in Moscow from 1966, and in Leningrad from 1976.
6Group therapy was favoured by many Soviet psychotherapists because it offered a way of delivering treatment to more patients in the conditions of time constraints and staff shortages. It was also presented as a way of making psychotherapy more cost-effective [32, 33].