SOCIAL PSYCHIATRY IN BULGARIA

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; in 1902 there were only two psychiatric wards and one asylum 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. The psychiatrist Nikola Krestnikoff studied in Paris and in Saint Petersburg and became interested in the treatment by psychological methods. Shortly before World War I, 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’s 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 associations without considering resistance and transference, 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 more 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 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 1920s and during the 1930s. At that time 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”. 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 1920s, were written in an objectivistic language; psychoanalytic structures were talked of as if they had a substantive reality. 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 1930s 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 1920s and 1930s of the past century the practice of psychotherapy in Bulgaria was reminiscent of Joseph Breuer’s and Sigmund Freud’s 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 personality analysis, and the others applied methods developed by themselves.

The World War II and the communist regime afterwards managed to completely prevent the further development of psychotherapy in Bulgaria. In the 1950s psychoanalysis, as well as psychology, were officially declared unscientific, and a vulgarized (“Marxist”) version of Pavlov’s 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 1950s and in the 1960s 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 Pavlov’s reflexology.

In the 1960s 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 fulfill this task he gathered a group of young psychiatrists who were instrumental in finding the psychoanalytical texts and reading them to him. By doing so they were able to learn more about psychoanalysis and to translate some basic psychoanalytic concepts into Bulgarian.

The group of Dr. Dimitrov and colleagues became interested in psychoanalytic group therapy. They were encouraged to apply group therapy as a substitute for individual psychoanalysis. In 1973 they got an appointment at the Medical Academy in Sofia; there they 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 counter-transference, training analysis and supervision. In this way they motivated a new generation of psychotherapists, many of whom play an important role in contemporary Bulgarian psychotherapy.

After Dr. Dimitrov’s death (1985) his students founded a standing seminar on psychotherapy which remained active until 1989. 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 1920s). By that time mainly group therapy was applied, influenced most of all by the interpersonal approach. These young psychotherapists managed, despite all the difficulties, to maintain contacts with a number of psychotherapists abroad. More contacts were made at the international congresses of group therapy (Zagreb, 1986) and family therapy (Prague, 1987).

Thanks to the efforts of the young professionals mentioned above to attract international trainers in April 1989 a psychodrama training program involving 10 participants was started in Sofia. This program was supported by the “National Neuroscience and Behavior Research Program” and the executive secretary of this program - Dr. Toma Tomov - was among the trainees. Although this training ended in 1994, the trainers still keep up their contacts with Bulgaria.

Psychotherapy is practiced mostly in private practice by single individuals. There is one counseling 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 counseling 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 programs to help drug addicts. These programs 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 not to work with every patient who comes.

What were the general preconditions and what the local specificities? Regarding the general conditions, three main factors can be identified: 1) intellectual resources drawing on the idea of a “holistic” approach to disease and therapy derived from an intensive debate on the “crisis of medicine” in the late Weimar republic; 2) long tradition of conflict and indeed rift between orthodox, institutionalized psychiatry and psychoanalysis; and 3) acknowledgement that the atrocities of Nazi medicine were the result of a one-sided and reductionist view of human beings.

The “crisis of medicine” was a widely debated issue from the mid-1920s. Physicians from all medical specialties, including surgeons like Erwin Lick and Ferdinand Sauerbruch, professors of internal medicine like Theodor Brugsch and Wilhelm His, gynaecologists like Bernhard Aschner, and bacteriologists like Hans Much joined in this discussion They claimed that a materialist or even mechanistic view of the patient predominated, with consequent loss of a “holistic” perspective integrating the biological with the psychological dimension of the sick person's suffering. The perceived modern ideal of the "Mediziner", a physician researcher focusing on the natural sciences, was contrasted with the supposed previous reality of the "Arzt", a family doctor interested in all dimensions of the life of his patient. Hippocrates or Paracelsus were named as the foremost examples of this ideal type of physician

This diagnosis of contemporary medicine led, however, to diverging conclusions: one tradition aimed at the reconstitution of “organic”, or “biological” unities, the search for hidden or forgotten healing forces in nature, and consequently turned away from scientific medicine to look for alternatives — for example, in naturopathy or homeopathy. This strand of ideas was in several ways compatible with already established movements and institutions of alternative medicine, and met with considerable sympathy among the broader public before and after 1933, and also among leading Nazi politicians. One of the reasons for this was that it also resonated with ideas of a healthy national organism (Volkskorper) which were central to racial hygiene and the social and health policy of the Nazi regime. As a matter of fact, during the first years of the new regime, all these movements received strong support from leading Nazi medical functionaries, and the newly created organization called "Reichsarbeitsgemeinschaft Neue Deutsche Heilkunde" (Reichs Working Group for New German Medicine), which attempted to integrate all these reform movements — including the first Association of Medical Psychotherapists (Allgemeine Arztliche Gesellschaft fur Psychotherapie) — was directly subordinated to the leader of the Reichs physicians, Gerhard Wagner.

A related, but more specific answer to the supposed “crisis” was the boost in the institutionalization of psychotherapy. The inauguration of the above mentioned Association of Medical Psychotherapists (founded in 1926 and mainly consisting of representatives of the somatic disciplines), the launch of journals devoted partly or wholly to matters of psychotherapy, and the establishment of a few psychoanalytically inspired clinics and sanatoria occurred in the late 1920s. All these developments may be understood as a reaction to a critique which realized that the subjectivity of the patient had disappeared from the agenda of mainstream, particularly academic, medicine. The interest in psychological factors of disease causation and symptom formation also resulted from a growing concern with the impact of war neuroses. The apparent increase in the number of such neurotic disabilities were seen as causing considerable challenges to the insurance system and to the national economy as a whole.

The initiatives to institutionalize psychotherapy experienced specific modifications during the Nazi period, caused in particular by the forced migration of Jewish psychoanalysts after 1933, but also by the increasing impact of various strands of “holistic” and other forms of psychotherapy. From 1936 onwards, there existed a central German Institute for Psychotherapy in Berlin which attempted to integrate different schools (Freudian, Jungian, Adlerian), and whose representatives served — among other purposes — as expert advisers for the air force and the army.

Diagnostic and therapeutic repertoire, professional networks and institutional structures created in these decades before 1945 represented resources which were used by the protagonists of post-1945 psychotherapy. A second factor contributing to the specific boom in psychotherapy before the Second World War, in particular in the form of psychosomatic medicine, was the continuing conflict between established psychiatry and psychoanalysis in Germany. The academic establishment of psychiatry in the decades around 1900 was in a way based on an adaptation of disease models, research strategies and approaches to preventive or therapeutic intervention which was oriented on the somatic disciplines, on experimental psychology, and ultimately the natural sciences. The success of this direction of psychiatry appeared certain with the foundation at Munich in 1917 of the German Institute for Psychiatric Research, which a few years later became part of the prestigious Kaiser-Wilhelm Society and served as a model for, among others, the Maudsley Hospital (founded in London in the 1920s) and the related Institute of Psychiatry.

In this context of professional politics in the early decades of the century, German psychiatrists denounced psychoanalysis as speculative and unscientific, and widely held the view that any alliance with its ideas or exponents might endanger psychiatry's newly achieved status as a “real” medical discipline. As a result, protagonists of psychiatry fought heavy rhetorical battles with psychoanalysis, and almost all available resources were directed to research into the somatic aspects of mental disorder, in particular neuropathology and genetics. Psychiatric genetics in particular was inextricably intertwined with eugenics. The first institution exclusively devoted to research in the inheritance of psychiatric disorders was the department of genealogy and demography at the German Psychiatric Research Institute in Munich. From its foundation in 1917 until the end of the Second World War in 1945, it was directed by Ernst Rudin, one of the protagonists of the racial hygiene movement in Germany. Judged in scientific terms, and by colleagues from Britain and the US, the research undertaken by Rudin and his co-operators was evaluated as outstanding in 1933/34, and as remarkable even in the post-1945 period. The aim of restructuring society according to the laws of biology was the guiding principle motivating all of Rudin's research and political activities. He and most of his staff were in one way or another involved in Nazi mental health policy, including active support of the systematic patient killings (“euthanasia”), and in research aimed at finding scientifically valid criteria for distinguishing between those worthy for procreation, or indeed worthy to live, and those supposedly unworthy.

In the immediate pre-war era, there existed some awareness about the scientific underpinnings of the atrocities in medicine and an acknowledgement that it had to do with a one-sided and reductionist view of human beings, associated with specific value judgments linked to prioritizing the health of the collective “folk body” (Volkskorper), or race. The neglect of the subjectivity of the individual patient appeared to be the common denominator for the features of medicine and health policies in the interwar decades: a purely biological-somatic approach to health and disease as prevalent in the dominant tradition of German psychiatry along with the radical pursuit of eugenic goals scientifically underpinned by genetics and the broader Nazi social and health policy that clearly subordinated individual wellbeing to that of the nation.

The developments described above illustrate that the core feature of pre-Second World War German psychotherapy was an institutionalization completely separate from psychiatry. The political willingness to compensate for apparent shortcomings and excesses of German medicine in the preceding period converged with the long standing resistance of German psychiatrists to the introduction of psychoanalytically inspired concepts and practices to mental health care and research. As a result since the mid-1950s, a number of local initiatives to establish independent psychoanalytically orientated psychotherapeutic programmes fell on fertile ground. The establishment of the "Department for Psychosomatic Medicine and Psychotherapy" at the University of Heidelberg illustrates in an exemplary fashion the impact of all these factors, and for almost four decades it served as a model for similar programmes elsewhere. Another major change were the rapidly growing number of sanatoria or rehabilitation hospitals, and psychotherapeutic services provided by single-handed practices which were all funded by the statutory health insurance companies or old-age pension schemes. With this, the broad split between psychiatry and psychotherapy on the levels of concepts, services and academic activities came to an end — a rift which had been the product of the medical and political history of twentieth-century Germany.

Mental Health is the doctrine of protection and the attainment of mental health. The term was already used in 1900 by the German psychiatrist Robert Sommer (1864-1937) at the Psychiatric Clinic of Giessen, established in 1896. However, only through the efforts of Clifford Whittingham Beers the situation of the mentally ill gained international recognition and greater awareness. The beginning of the modern mental hygiene era in the literature is acknowledged with the publication of the book by C. W. Beers, "Mind that Found Itself" (1908).

1. Concern for the preservation of mental health, prevention of mental illness, nervous diseases and defect states;

3. Education about the importance of studying mental abnormality to the problems of economic and social life, crime, and all of human behavior.

These tasks should be fulfilled by promoting social welfare and interaction with public and private welfare institutions.

Addendum: The iceberg of psychiatric illness in Bulgaria posed considerable difficulties to the editor of this miscellany. No good history of psychiatry exist in this country written in Bulgarian language. It is not because there is a lack of qualified psychiatrists and psychotherapists around — whatsoever, the distinction between those two sub-disciplines in the Medical Faculty, Sofia, is rather blurred.

This review is exempting the theoretical background of (Mental) Health, its definition from World Health Organization and allied non-governmental institutions; furthermore, we tried to consolidate our knowledge and give in a shell some directions for future research. Here is a three point scheme:

1. The founding authorities of disciplinary psychiatry (and neurology) in Bulgaria were russian émigré professors, dully appointed at the MF from 1918 — viz., Prof. Nikolai Popov (1860-1939) and Prof. Alexei Yanishevski (1873-1936). They read lectures and taught clinical practice in Sofia until retirement;

2. The bulgarian mentors of psychosomatic medicine and psychotherapy, Dr. S. Danadjiev and Dr. N. Krustnikov (and maybe some other unreferenced), have remained anonymous since end of Second World War. They were disclaimed as pro-nationalist, while counseling work of both was stained with eugenic measures and some elements of psychoanalysis — viz., communication practice to patients with clinically established diagnosis;

3. Repertoire medical literature in the subject is rare, specifically in compliance with international standards and references. Thus we could expound at least three monographs in Bulgarian language that fulfill the criteria — G. Uzunov's (translator and editor) "Textbook of Psychiatry", K. Cholakov's "Freud Psychoanalysis and its Critical Examination", and P. Nikoevski's "Chronic Alcohol Disease", ditto.

(i). Prof. Georgi Uzunov (1904-1971), member of the BAS and the Academy of USSR — viz., specialized in Neuro-pathology and Psychiatry. He was highly instrumental in reorganizing psychiatric care in Bulgaria on the basis of Soviet models and principles.