France

Country

• 64,7 million inhabitants, density of 114.44 habitants/km2
• Expenditure on health : EUR 232 billion (12% of the health current expenditure)
• Mental health expenditure : EUR 107 billion (direct expenditure linked with health and social structures : EUR 20 billion; expenditure linked with sick leave and quality of life: EUR 87 billion)

Psychotherapy in the health care system

• Psychotherapeutic practice is not differentiated from clinical practice of psychiatrists and clinical psychologists; psychotherapy is essentially practiced by private psychiatrists (practitioners in public mental health structures have in priority to prescribe medications and to manage health professional teams, especially in public psychiatric hospitals) and clinical psychologists in private office, private and public health and social institutions.
  Psychotherapy is fully integrated as a potential activity of psychiatrists and clinical psychologists. The social insurance system only recognizes medical acts or psychiatric act (so, psychotherapy is possibly partly reimbursed as a psychiatric consultation); psychological interventions are not integrated in it because of the professional autonomy of clinical psychologists who don’t depend from medical practitioners.
• Indication: all mental and behavioural disorders, all psychological and existential difficulties.
• Quality management requirements: guidelines for different somatic and psychosocial situations which imply psychological aspects (as Alzheimer disease or authors of sexual aggressions on minor people) integrate some recommendations on psychotherapy in the framework of the general therapeutic taking care, recommendations established by the Health High Authority of the Health Ministry. The same recommendations for psychotherapy are established for mental disorders general taking care (as mental anorexia, psychopathy, autism, anxious disorders or complication of a depressive episode among adults and so on).
• Patients’ access: a patient can be directly consult in first intention a psychiatrist or a clinical psychologist; he can be also addressed to a psychologist by another psychologist, a medical practitioner or a nurse; psychotherapy is not prescribed and doesn’t belong to the nomenclature of the social insurance system, in spite of the fact the medical body would want since years to submit psychotherapeutic activity of the psychologists to the medical guardianship.

Psychotherapeutic Professionals

• Professions, qualifications prior to specialization and postgraduate training in psychotherapy, accepted psychotherapeutic schools/approaches:
• Psychotherapeutic practice is not protected by law in France, everybody can practice psychotherapy with or without any training!
• Only the title of “psychotherapist“ is protected by law since 2004 (law n° 2004-806, 9th of August 2004 related to public health politics), completed by an application decree of 2010 (decree n° 2010-534, 20th of May 2010 related to use of the title “psychotherapist“) which defines training conditions :
• first : to have :
  - a medicine doctorate (general practitioner or specialist)
  - or a master in psychology (every specialisation)
  - or a master in psychoanalysis
  - or to belong to a psychoanalysts association
   
• second: to follow a complementary theoretical and practical training in clinical psychopathology defined by the law, training the number of the hours depends from the basic training. This training is supposed to obtain and to validate knowledge related to :
  - the human being development, his psychological functionment and the psychic processes;
  - the discrimination criteria of the main psychiatric disorders;
  - the different theories connected with psychopathlogy;
  - the main approaches used in psychotherapy.
   
• The law doesn’t mention any compulsory psychotherapy training to legally use the title of “psychotherapist“, so the French law makes a confusion between psychopathology training (which is highly recommended as a basic training to practice psychotherapy) and a practical psychotherapy training (personal psychotherapy, supervision and supervised practice). This paradox situation prepares legally future users of the title “psychotherapist“ to practice psychotherapy without any psychotherapy training … The French law made the confusion between a basic psychopathology training (which is not defined as a basic one but as the only compulsory training to use the title) and a really psychotherapy training!
• The main French organizations of psychologists put an annulment recourse to the State Council about this 2010 decree… We wait for the result… EuroPsy certification process for psychologists specialized in psychotherapy is an interesting alternative for French psychologists because it’s based on real psychotherapy training criteria!
• Only psychiatrists have not to follow any complementary training: they are considered by law competent as “psychotherapist“ on the base of their basic academic university training! People who want to use the title of “psychotherapist“ (it’s not compulsory to practice psychotherapy!) will have to be inscribed on the national register of psychotherapists (defined by the 2004 law): the general situation is to follow a minimum of 400 hours of psychopathology and a placement of a minimum of 5 months; the following table (integrated in the decree) summaries the different cases :

Psychotherapy for Depression

• In case of outpatient treatment of an isolated depressive episode (Health High Authority 2002): cognitive and behavioural therapies, support psychotherapies and interpersonal therapies were the object of controlled studies in light and moderated depressions. Psychoanalytical psychotherapies can be a useful option at a distance of the intense phase. It’s not proved that combination between antidepressants and psychotherapy is more effective than just psychotherapy in light and moderate forms of depression. Combination between antidepressants and psychotherapy can be proposed in the case of psychosocial difficulties having marked consequences on life patients. In severe depressive episodes, antidepressants are essential but association with psychotherapy can be proposed.
• In case of recurrent or persistent depressive disorders of adult, about the aim of structured psychotherapies (Health High Authority 2009: psychotherapy is highly recommended when coexist personality disorders, current or ancient psychological conflicts, interpersonal difficulties or when the patient expresses the demand of such an help.
• In case of complication of a depressive episode among adults (Health High Authority 2007):
  - recurrence prevention:
  -> if 2 characterized depressed episode (CDE) in 4 years, even only 1: only psychotherapy;
  -> if 3 CDE or more in 4 years or more spaced but with risk factors: antidepressants and psychotherapy.
  - in case of chronic depression : after symptoms remission, treatment maintenance by antidepressants and psychotherapy during 18 months to 2 years.
  
   

Desirable Changes to Health Policy

• If you were responsible for health policy in your country, what would your first decision be regarding psychotherapeutic care?
• To suppress the current law on protected title of “psychotherapist“ and to replace it by a new law including criteria about psychotherapy training and protecting psychotherapy practice only reserved to psychiatrists and psychologists.

Additional Information

• We are confronted in France since 20 years with a very active lobbying of “psychotherapists“ associations which essentially gather no-psychiatrists and no-psychologists and which fight to establish a new profession practicing psychotherapy independently from psychiatry and psychology, with a high connection to the European Association for Psychotherapy and the World Council for Psychotherapy, on the model of what happened in Austria with the new profession of psychotherapist in 1990. It’s an ethical question of users protection to have the requirement of a high level of basic academic university training in psychopathology and a high level of post-graduate psychotherapy training. That’s the reason why we struggle against both these organizations and against the current public health policy which demands a low training on only a part of what is required to practice psychotherapy.

Author
Philippe Grosbois, psychologist, senior lecturer in clinical psychology and psychopathology, health anthropologist, Angers University, representative on psychotherapy in the French Federation of Psychologists and Psychology (FFPP), previous convenor and member of the EFPA Standing Committee on Psychotherapy (European Federation of Psychologists Associations), member of the Council of the International Federation for Psychotherapy.

The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".

You can download the paper here.