Lativa

Country

• Latvia is a small country, of just 64 590 square kilometers , and approximately 2 266 600 inhabitants by 20010, which corresponds to a population density of about 35 persons per square kilometer. Most of population is concentrated in Capital Riga and few other biggest towns of Latvia.
• Expenditure on health care in 2009: EUR 512 Million (2008=5.8% of the gross domestic product). In 2010 total budget of the Ministry of Welfare was 486.536 milj Lati, from this budget 360.023 M were spent on General Medical Health Care, 51.452 M on Special Medical Health Care, and 255.182 M on Therapy.T he costs caused directly by mental and behavioral disorders are not published, and they are quite small. Psychotherapeutic health care receives very little finances.

Psychotherapy in the health care system

• By the Law psychotherapy in public health care is mainly provided by specialists with full 6 year medical academic education.
• According to the Psychotherapists’ Specialty Regulations, issued by the Latvian Welfare Ministry in 2002 , psychotherapy has the following definition: Psychotherapy is a primary medical specialty of a psychodynamic psychiatrist and a doctor in Psychosomatic Medicine (hereinafter - the psychotherapist), which addresses disease, suffering and impairment (mental, psychosomatic, somatopsihisko, behavioral, affective, cognitive, and relationship and sex life), and provides etiologies, pathogenesis, diagnosis, treatment, prevention and rehabilitation, based on an integrative biopsychosocial approach. Historically psychotherapy has started with a psychodynamic school, mainly by doctors, in Latvia in 1991, hence it is well rooted in contemporary medicine by now, has the only academic postgraduate training programme, and therefore, Latvian Ministry of Welfare gives priority to the psychodynamic psychotherapy approach.
• These psychoanalyticly informed psychotherapists with a medical academic background, together with just a few psychologists, who have received professional training and accreditation abroad, are joined in the Latvian Association of Psychotherapists LPTA, ( full name of the doctors-psychotherapists Association is ‚Latvian Association of Psychodynamic Psychiatry, Psychosomatic Medicine and Psychotherapy’ website . http://www.arstipsihoterapeiti.lv) LPTA forms a section of the Association of Doctors of Latvia called ‘Latvijas Ārstu Biedrība’ (LAB), and follows professional requirements of the European Federation for Psychoanalytic Psychotherapy (EFPP); LPTA is a member of the EFPP.
• Section for Psychoanalytical psychotherapy is the largest one in the Latvian Association for Psychotherapy (LAP), smaler others are the Family systemic therapy, group therapy and, Children and Adolescents section.
  - Types of psychotherapeutic treatments available: Predominantly individual psychodynamic psychotherapy, including psychoanalytic psychotherapy, provided by psychiatrists and doctors with further specialization in psychotherapy.
  - Indication: various, limited access
  - Preconditions (e.g. prior authorisation, prior treatments): various, limited access.
  - Quality management requirements (guidelines, outcome evaluation): Psychotherapy practice is public health sector is regulated by the Psychotherapists’ Specialty Regulations, issued by the Latvian Ministry of Welfare in 2002, Certification with the LPTA – Latvian Psychotherapy Association, and other documents under the Latvian Ministry of Welfare. under a section of the LAB .
   
• Psychotherapy title and practice in private sector is not regulated by Law in Latvia.
• Some psychotherapy outcome evaluation research has been recently started in University hospital training and research centers under guidance of the Department Psychosomatic Medicine and Psychotherapy, Riga Stradiņš University.
  - Patients’ access (e.g. direct access, access via a general practitioner or specialists): various; limited access.

Psychotherapeutic Professionals

• Professions, qualifications prior to specialisation and postgraduate training in psychotherapy, accepted psychotherapeutic schools/approaches.
• Accredited postgraduate training in Psychotherapy , access limited for health professionals only.
• Riga Stradiņš University http://www.rsu.lv/eng http://www.stradini.lv offers two certified further professional specialization programmes at the Faculty of Continuing Education: (1) Psychiatrist – Psychotherapist (6 years 396 ECTS), and (2) Psychotherapist (4 years 264 ECTS).
  •Target group for residency: persons who wish to continue their studies for specialisation having completed higher medical education and having been awarded M.D. degree (diploma of EU standarts).
• Title of the Study Programme: Residency in Medicine.
• Degree Awarded: Specialist Qualification Diploma.
• Professional Body of these psychotherapists is Latvian Association of Psychodynamic Psychiatry, Psychosomatic Medicine and Psychotherapy. http://www.arstipsihoterapeiti.lv., a member of the European Federation for Psychoanalytic Psychotherapy (EFPP, www.efpp.org/ )
• An individual route of training in psychodynamic therapy under supervision of licensed doctor-psychotherapist by LPTA is also recognized and available.
• Psychotherapy in the private sector is provided by psychotherapists of vide variety of schools, such as Analytical psychology, Art therapy, Ericksons suggestive therapy, Existential psychotherapy, Family Systemic therapy Gesttalt therapy, Hypnotherapy, Integrative psychotherapy, Play therapy, Psychoanalytical psychotherapy, Psychodrama, Psychodynamic psychotherapy, Psychoorganic analysis. Number of approaches is continuously increasing. These psychotherapists have different forms and levels of training. Few of them have received internationally recognized accredited training and certification abroad, the rest have been trained in private institutions in Latvia, who have no accredited training programmes and no entering requirements.
• Majority of psychotherapists with different basic academic educational background (doctors, psychologists, social workers, etc.,) are united in the Latvian Psychotherapists Association, LPA, (former Union of Psychotherapy Associations of Latvia), ( http://psihoterapija.lv). LPA is a member of the European Association for Psychotherapy (EAP), LPA defines psychotherapy as independent and free profession, it provides certification and registration of its members according to the EAP requirements. At present, there are 125 certified psychotherapists in the LPA Register of Psychotherapists. They represent 9 major psychotherapy approaches in Latvia.
• Non-doctor psychotherapist practice is not regulated by the Law in Latvia. They are practicing, paying taxes, with no control.
• In the private sector clients pay for psychotherapy themselves. No insurance cover psychotherapy costs. Citizens can claim return expenses for health services from State revenue service. It is possible to get taxes back for payments for non-medical private psychotherapy services. (Depending on SRS clerk)
• Requirements for providing services within the health care system: Only about 50 doctors – psychotherapists are qualified to work in the health care system at present, and approximately the same – clinical psychologists, which are working in a team under supervision and providing special services, according to the Act on “Complimentary medical professions”, from 2009). They are not allowed to practice as psychotherapists by the Law.
• The posts of psychotherapist are very limited. Often persons, providing psychotherapy services have a different job title.
• Additional services (prescriptions, assignments) the same: only doctors and doctors – psychotherapists are allowed to make prescriptions, assignments .

Psychotherapy for Depression

• Special concepts (apart from 3.) Within the health care system Certified Psychotherapists work in multidisciplinary teams and provide a psychoanalytically informed psychodynamic psychotherapy based on an integrative biopsychosocial approach, which is a good practice model.
• Shortcomings: Lack of certified training programs apart from those 2 at the Riga Stradiņš University - provided only for trainees with a medical educational background; lack of certified psychotherapists, lack of financial support and placements.
• Severe forms of depression are treated by psychiatrists, using psychopharmacology in the state health care system. Antidepressants often are prescribed not only by psychiatrists, but also by GPs. Psychotherapy of depression is mostly accessible only for patients willing and able to pay for themselves.

Desirable Changes to Health Policy

• If you were responsible for health policy in your country, what would your first decision be regarding psychotherapeutic care?
• Develop new, more inclusive legislation in Psychotherapy which corresponds to the present achievements in psychotherapy development in Latvia.
• Introduce Professional Regulation for psychologists-psychotherapists with standards for training, and certification similar to those, implemented for doctors-psychotherapists by the Latvian Association of Psychodynamic Psychiatry, Psychosomatic medicine and Psychotherapy.
• Overcome obstacles for cooperation, introduce multidisciplinary work practice in health care, and enhance the role of psychologists in it.
• Develop multidisciplinary training programmes aiming at strengthening cooperation of psychotherapists with medical and psychological academic background within the Accredited postgraduate training in programme in Psychotherapy.

Additional Information

• Profession of psychotherapy appeared around 1990 in Latvia, and has developed mainly as an outgrowth of psychoanalytic psychotherapy. It was developed within a community of doctors and few psychologists, because there were very few psychologists and no social workers in the Soviet system.
• Psychotherapists are divided in Latvia between doctors-psychotherapists, and non-doctors psychotherapists. Psychologists-psychotherapists are not recognized by the Law and organized in a separate professional body. Psychology itself is not regulated by the Law yet. There is an ongoing debate on how to define clinical psychologists working in the public health care system, which prevents fruitful cooperation and joint actions in further development of psychotherapy as profession regulated by Law.

Author
Dr. Sarmite Lucava, Practicing psychologist-psychoana¬lyst; Member of the EFPA Specialist Eupean Awarding Committee in Psychotherapy. Mag. Ansis Jurgis Stabingis, Psychologist, Psychotherapist, Registrar of of the Latvian Register of Psychotherapists, the Latvian Association of Psychotherapists.

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.