"Psychotherapy is too valuable to be reserved only for clinic patients."

Takie Dela, October 2024

October marks World Mental Health Day, celebrated worldwide. Olga Movchan, a psychotherapist with 20 years of experience, is also a lecturer and supervisor. Takie Dela spoke with her about how people’s needs for specialist help and approaches to psychotherapy have changed over the past century.

In the 19th century, people with psychological and mental health issues were treated with brutal methods. Often, these methods not only worsened their mental and physical condition but sometimes led to death. Take, for example, inhumane practices like lobotomies or electroshock therapy.

Sigmund Freud was the first to use conversations with patients as a therapeutic method, marking the beginning of psychotherapy. At first, this new approach was only available in a few psychiatric clinics, and the decision to pursue therapy was made exclusively by specialists.

In some countries, such as the USSR, these clinics became a unique type of prison through "punitive medicine," used to punish dissidents.

Over time, both in Russia and around the world, approaches and methods of psychotherapy changed, and therapy became a part of life for many—even those without mental health diagnoses. Today, clients rather than doctors define the issues for which they seek help.

The Beginning of Psychotherapy: Conversations Instead of Electroshock

— When can we say psychotherapy truly began?

— Essentially, from the moment humans existed. In ancient times, any attempt to help someone better understand a situation or realize what was happening could be considered psychological assistance. This could include shamanic practices, discussions with Indian gurus, or conversations with rabbis or priests about life situations.

— But none of this was based on scientific data, right?

— No, it wasn’t. In fact, the development of psychology as a science was largely separate from practice, although it generated a lot of interest. Since ancient times, philosophers have pondered what the soul is and how it connects with the body. But that was an attempt to explain rather than to help.

Experimental schools emerged in the late 19th century—Vladimir Bekhterev in Russia, Jean Charcot in France, Sigmund Freud in Austria. Doctors began testing their accumulated hypotheses on patients. There is a legend that the origin of psychoanalysis was linked to Freud’s difficulties with hypnosis, which he had learned from Janet and Breuer (pioneers of psychotherapy). As a result, he sought ways to achieve similar effects while the patient remained awake.

Whether this is true or not, Freud undeniably created a new branch of psychiatry based on conversing with patients.

— So, these were still considered patients, not clients?

— Yes, psychoanalysis was part of psychiatry, meaning it was part of medicine.

— Was there such a concept as a request for help back then, or did psychiatrists themselves choose the problems they were interested in and research them in their patients?

— Psychiatrists themselves formulated the issues; people didn’t come with their own requests. For example, Freud’s patients, whom he studied under the label of “hysteria,” did not approach him for help—they were brought to him as “mentally deficient.”

Psychiatric clinics were grim places, reminiscent of prisons. Most hospitalizations were forced; no one wanted to end up in such terrible conditions.

The idea of seeking therapy emerged much later, after the end of World War II, when psychoanalysis began to be practiced outside of clinical settings.

— What kinds of prejudices did researchers and psychiatrists of the time impose as labels on their patients, and where did that lead? Take, for instance, “hysteria.” In the late 19th and early 20th centuries, it was labeled a condition “native to women and originating in the womb.” In reality, many of Freud’s patients had suffered from sexual violence, yet women were not believed.

— This attitude was tied to women’s status in society at the time. Back then, women were seldom asked whom they wanted to marry. They had no rights and were constantly coerced. Women lived in a state of perpetual trauma that was impossible to process. Today, we understand that this could indeed lead to hysterical symptoms.

Meanwhile, the treatments for hysteria were quite horrendous.

— Such as?

— Electric shocks, restraints, isolation from people. Freud was among the first to talk to these patients and try to understand what was happening to them. It’s no surprise his therapy was effective.

— So, they were no longer tied down or shocked—that was already an improvement.

— Exactly, and that alone proved to be effective.

Post-War Years: Psychotherapy Moves Out of Clinics

— What did World War II change? Why did psychological counseling become accessible to everyone, not just clinic patients, after the war?

— People had long noticed that something happened to the psyche during war. Symptoms of war trauma were described by Shakespeare and in memoirs about the Napoleonic Wars and World War I. However, only after World War II did significant studies of “war neuroses” and “battle fatigue” emerge—what, since the 1970s, has been called PTSD (post-traumatic stress disorder).

Many veterans came forward with complaints of various physical symptoms: sleep disturbances, shortness of breath, feelings of heart attacks. None of this was described as “panic attacks,” but psychiatrists started working with other specialists, like cardiologists, to explore the somatic symptoms related to psychological causes.

Gradually, psychotherapy gained popularity. People began to seek it out to understand themselves better. As American psychotherapists Erving and Miriam Polster later wrote, “Psychotherapy is too good to be left only to clinic patients.” There was a hope that soon everyone would become self-aware.

This backdrop led to the rise of the anti-psychiatry movement in the 1960s, advocating for the rights of the mentally ill. Although it generated controversy, it also gave birth to movements for inclusion and recognition of the rights of various minorities for the first time.

In the 1970s, unions of mentally ill individuals began forming to fight for their rights. They had many utopian and somewhat dangerous ideas—for instance, the notion that mental illnesses shouldn’t be treated at all. Still, these movements had a positive impact on conditions in psychiatric clinics. Treatment in European and American clinics ceased to be compulsory, except in rare cases such as acute psychosis. Treatment methods also became more humane.

— Did this trend reach Russia?

— Unfortunately, no. In the USSR, psychiatry was effectively an instrument for suppressing dissent. Dissidents were given fictitious diagnoses like “sluggish schizophrenia,” and doctors employed dreadful methods: insulin shock, administering haloperidol without proper indications.

Incidentally, remnants of this system made many of our compatriots reluctant to seek help, even for symptoms of PTSD—it seemed too risky.

— How do people’s needs change depending on how much time has passed since combat ended?

— During wars, the value of belonging in society increases exponentially. The division into “us versus them” becomes a survival necessity. On one hand, there is an enemy; on the other, there’s someone on your side who will support you. Individual needs are pushed to the background.

In post-war periods, like the 1950s, people try not only to work through trauma but also to discover their personal needs. They come to therapy asking, “What do I even want? I’ve been following societal norms, but where am I in all this?”

Then comes the next generation—let’s say, the 1970s. Usually, they are raised in families where adults have little energy left for caring for their children or attending to their needs. Parents are not accustomed to thinking about their needs, and child-rearing comes down to ensuring the child is fed and attends school. Often, children are expected to achieve specific milestones: getting into university, securing a prestigious job. Belonging is important, not individuality. These children, as they grow, seek to reclaim autonomy. They try to undo the choices made for them. This too can be a reason to seek therapy.

And then their children—those born in the 1990s—feel a renewed need for belonging. They long for closeness while their parents are busy achieving. In such families, it’s often uncommon to gather for dinner—autonomy is seen as a value. So, children seek belonging elsewhere, leading to the formation of various subcultures. Yet, they still struggle to build close relationships, another reason they seek therapy: “I love one person, but I’m married to another. What should I do?” Questions of identity, such as “Who am I in this world?”, once again become relevant.

Our Age: Uncertainty

— In the 2000s and 2010s, uncertainty in society increased. Life began to accelerate rapidly; communication moved more and more into the virtual realm. In my observations, people have found it increasingly difficult to interact with others. They come with issues like “I have trouble connecting with others, relationships are hard.” Many feel anxious about an uncertain future.

This periodization was proposed by Italian Gestalt therapist Margherita Spagnolo Lobb. It can’t be fully applied to Russia, as societal development there followed a somewhat different timeline. Still, the emotional states experienced during COVID-19 were similar in Russia, Europe, and the US.

— Speaking of online communication, in recent years, interactions between psychologists and clients have also moved online. How has this affected the therapy process?

— First COVID, then the mass migration of Russian-speaking clients and therapists led to therapy being more frequently conducted online. Despite the skepticism initially voiced by many colleagues, research showed that, with some exceptions, online psychotherapy can be comparable to in-person therapy. Furthermore, in some cases, online therapy allows freer work with certain topics, such as sexuality. Concerns that therapist and client would turn into mere ‘talking heads’ have also gradually subsided. Therapists have learned to freely suggest clients change postures or make movements despite the online format. Still, in some cases, such as severe depression (especially with suicidal thoughts) and certain forms of trauma, in-person therapy works better. Personally, I prefer in-person sessions, though I do a lot of online work as well.

— We talked about the destigmatization of mental health diagnoses, which played an important role in the 1960s and 1970s. How are disorders viewed in the 21st century?

— Modern psychotherapy tends to focus not on diagnoses but on experiences. For example, a person may have had a traumatic experience, but they are capable of overcoming it. This emphasizes the dynamic nature of the situation—it’s not a lifelong diagnosis. Right now, the experience is like this, but it can change. People are free; we don’t label them. Another trend among contemporary therapists is focusing on interactions with the environment. Today, the client is not seen as an isolated individual. We understand that they are surrounded by others and cannot always take full responsibility for what happens to them—such as in an abusive relationship. To begin working through trauma, one must first leave the abusive environment.

— When did people in Russia start turning to psychotherapists without associating it with punitive psychiatry, without feeling ashamed? Has this shift fully happened yet?

— I think interest in psychotherapy in Russia surged after Perestroika. In the early 1990s, conditions in psychiatric clinics began to change. Discussions arose about the rights of mentally ill individuals and the inadmissibility of forced hospitalization. Psychology professors started visiting the country, and various schools emerged—psychoanalysis, Gestalt therapy, behavioral therapy.

— Through public awareness, many also learned about different diagnoses. Did this lead to more people seeking therapy? And is there a downside to this popularity?

— The tremendous amount of information about mental conditions, along with the respect for personal characteristics and experiences that’s now more common in society, significantly reduces stigmatization. This means people are more comfortable seeking help. However, this phenomenon does indeed have a downside.

Firstly, self-diagnosis or amateur diagnosis leads to an increase in psychopathology. Inaccurate or incorrect diagnoses can cause fear, alter lifestyles, or lead to self-medication.

Secondly, today’s society focuses far more on vulnerability than on adaptability. Such a one-sided approach can hinder coping with challenging experiences. This is a kind of ‘reverse stigmatization’ that creates room for manipulation, speculation, and confusion. For instance, someone who has experienced trauma but hasn’t processed it and hasn’t sought help may not realize that they are behaving in a traumatizing way toward others. Society often sympathizes with them as the ‘weaker’ party, justifying their actions based on past experiences. This kind of injustice amplifies the trauma and prevents it from being resolved.

— From your recent practice, are there still issues that clients find too shameful to address, ones they are afraid to bring up?

— Unfortunately, people with trauma rarely seek help. This is a symptom of traumatic experience, which has become quite common in recent years, except in the case of pronounced PTSD. As in the mid-20th century, people are more likely to come in with complaints about physical symptoms.

People are particularly reluctant to talk about sexual violence—it remains a taboo subject. Instead, they may discuss issues in their sex lives: lack of desire, fear of entering a relationship. Through these concerns, the root cause, often related to violence, can be addressed.

Individuals with addictions also rarely seek psychological help. And if we consider gender imbalances, I think the idea that ‘boys don’t cry’ still lingers in Russia, especially given the wartime context, where men are expected to become soldiers. Even in the 2000s and 2010s, I had clients who found it hard to express their feelings—they saw it as something dangerous that might lead to judgment.

— But overall, are there now more men in therapy sessions?

— In my experience, yes. Psychotherapy has become more familiar. More couples are seeking family therapy. Men discover that it’s not so bad, and then they start seeing a personal therapist. Still, the proportion of women in therapy remains much higher than that of men.

— Is there a difference in therapy requests between Russians who stayed in the country and those who emigrated?

— There’s a big difference, although everyone is grieving—both those who left and those who stayed.

The main questions for emigrants are related to adaptation in the new place. But during therapy, it often becomes clear that they are also experiencing a loss. This feeling is often suppressed, but discussing it is an important part of the work; without it, adaptation in a new place isn’t possible.

As for people in Russia, society has become deeply divided. Those who do not agree with what’s happening find themselves struggling to survive, making difficult choices. Many complain of losing sensitivity—as if they don’t notice reality. This is a defense mechanism to avoid losing their mind in such a context.

The Future: Searching for Anchors

— When did children become clients of psychotherapists?

— Interest in children’s psychology emerged in the late 19th century. Psychoanalysis contributed significantly to this idea, asserting that many problems originate in childhood. Scientists began studying early development.

In the 20th century, there was increasing emphasis on children’s rights. These social changes spurred an interest in child and adolescent psychology. After the war, Freud’s daughter Anna began working specifically with children.

Child therapist Natasha Kedrova perfectly described the evolution of parental requests, since adults are typically the initiators of child therapy. In the 1990s and 2000s, the most common request was, “My child is not right; fix them. Make them obedient and successful in school.” In the 2000s and 2010s, this changed to “Help us understand each other.” More recently, parents have been saying, “My child is unhappy; they want nothing.” And this is true—in an unstable world, a child doesn’t know what they truly want. They are lost.

Both adults and children will need to cope with this challenge. Psychotherapy will help in finding stability and support.