The author describes the Italian law which, since 1989, has regulated the practice of psychotherapy in Italy–and its complex implications for psychoanalysis. Even if the Ossicini Law does not specifically mention psychoanalysis, in fact all Italian analytic schools subjected themselves to its legal requirements, which meant accepting only graduates in medicine or psychology for training.
A dramatic change took place in Italy in 1989 with the passage of the Ossicini Act, which regulated the practice of psychotherapy by establishing that:
(a) those holding a Laurea in Psicologia—degree in Psychology—have a right to membership in a Psychology “Order” (in Italy ordine is the medieval term for a professional association protected by the state);
(b) psychotherapy can only be practiced by psychiatrists (MDs) or psychologists who have obtained a diploma in Psychotherapy following at least four years of specialization in psychotherapy in a State-accredited public or private school; and
(c) psychotherapy practiced by persons other than officially recognized psychiatrists and psychologists is considered illegal and therefore liable to legal prosecution.
The Ossicini Act was partially a consequence of the Verdiglione Trial a few years earlier. Armando Verdiglione—a very wealthy Lacanian psychoanalyst who was not an MD—was accused and convicted in 1986 of having taken advantage of immature and weak personalities, his patients. In fact, some of his analysands were economically ruined through financing Verdiglione’s huge cultural enterprises, which later went bankrupt. The media had in fact provided extraordinary coverage of this trial, and public opinion—largely hostile towards Verdiglione—gave voice to a problem: “When we go to an analyst, into whose hands are we putting ourselves? What if the analyst is a fraud”? Ossicini—a Catholic communist member of Parliament, one of the first Italian psychoanalysts, and a university professor of psychology—had been putting forth his proposals for almost twenty years, and this bill finally saw them recognized.
The vast majority of psychologists and analysts then—especially from the left—favored the Ossicini Act, since it looked like a measure for reducing the power of doctors and making room for psychology laureati (graduates). Ossicini was in actual fact advocating the “psychologists’ cause”, specifically, that of his students. At that time, the SPI (Italian Psychoanalytic Society)—the Italian branch of the IPA—accepted into analytic training only one out of ten non-medically trained candidates. Formally speaking, until 1989 only M.D. psychiatrists could practice psychotherapy—but I repeat, “formally speaking”, since there were, of course, any number of psychotherapists and analysts who were not doctors. The spirit of the Ossicini Act was initially non-medical or even anti-medical.
It ought to be noted—is it pure coincidence?—that in the US in 1988 a ruling by the Supreme Court required the IPA to open its doors to non-medically trained analysts. I think that these changes in Italy and America at the time marked a symbolic turning point towards what one could call the de-medicalization of psychoanalysis. This de-medicalization resulted not from laws, but from history: there are increasingly fewer MDs working as psychoanalysts and psychotherapists; psychiatry has once again become organicist, and the “talking cure” is now left to psychologists (and, in the US, also to social workers). Psychoanalysis as a profession is becoming increasingly more feminized, more de-medicalized and also more de-scientized (I hope the reader will excuse these awkward neologisms). This process is more advanced in English-speaking countries, although I think that it will spread everywhere. It is in this context of historic transformation that one needs to consider the legislative changes.
Under pressure from the SPI (the Italian IPA) all references to psychoanalysis were removed from the bill, which theoretically should have left the situation of analysts unchanged. But there is an ambiguity in every exclusion, even if it be self-exclusion, owing possibly to privilege or marginalization. A situation of privilege can turn into marginalization or vice versa—history provides us with numerous examples of this. Whence the initial doubt on the part of analysts: “Must we mark our difference with respect to ‘other’ psychotherapists by excluding ourselves from regulation, or might this difference harm us”? In fact, it was Kultur that decided. Analytic schools soon realized that their self-exclusion from regulation, in order to maintain their freedom, implied too great a cost in terms of power: to begin with, a fall in enrollment and requests for training. In the 1980s I taught at the Experimental Center of Psychoanalysis in Rome, an analytic school I had co-founded: in the year the Ossicini Act was passed, enrollment dropped by 50%. Potential students wanted to know whether or not our Center would be recognized by the State before enrolling.
One can in theory open schools of psychoanalysis and train analysts without worrying in the least about being recognized as “psychotherapists”—the hard-line, or what I would call puritanical, analysts do just that. In practice, the majority of analysts—including Lacanians—are keen on legalizing their status. But the fear of being reported for illegally practicing as psychotherapists is probably the last reason to impel them to legalize their status. For example, analysands—or patients, the old term still holds sway in Italy—may at times request a receipt for their payment: this allows them to deduct psychotherapeutic expenses from their taxes. Now, if an analyst is not recognized as a psychotherapist, he cannot provide a receipt, and so risks losing clients. Moreover, analysts frequently hold other more or less “institutional” positions, often within the public healthcare system or in the private sector: if one’s status is not official, then clearly one can’t be hired. Especially among young analysts, the inability to support oneself by means of one’s analytic practice alone is considered “unhealthy”, a professional risk: one is thus forced to accept into treatment almost anyone who walks in, to unconsciously extend analysis, and so on. In short, living only from analytic practice is seen as a source of anxiety—only an established and well-known analyst can allow himself the luxury of living exclusively from his private practice. A young person entering analytic training wants to keep open the possibilities for activities other than that carried out in his private office. What’s more, there’s a widespread feeling that psychoanalysis as a profession probably won’t last forever: what if it disappears in 10 or 20 years? One would like at least to be left with a safe way out.
It was both a disappointment and shock for older analysts to see that their cherished students were in need of recognition, legalization—in short, of respectability. They realized that the purely private recognition bestowed by their institute or society (a purely symbolic recognition) was usually insufficient for them. The liberal and anarchist ideals of many of the older analysts—coming mostly from the political left—encountered the not-so-ideal reality of their students.
Thus, even if the Will of the Lawmaker does not seek to regulate psychoanalysis, analysts in fact prefer being regulated by it: it’s a self-submission to the law. Yet it’s remarkable that many analysts accuse the Ossicini Act of restraining them: self-restraint is often “paranoised”, if you will.
There are two common attitudes among Italian analysts-managers who face this problem. One group considers all this a simple bureaucratic fiction: “legalizing the status” of their school is the same as obtaining a passport, an identity card or a birth certificate. It is bothersome, but in the end you can carry on forming analysts as you want. The other group, in contrast, tends to think that the law has changed the rules of the game, and that the training of analysts and practice itself have been changed for the worse by legislative measures. The fact that only doctors and psychologists are recognized has changed, in their opinion, the type of candidates entering the analytic profession, and in the long run this will change the nature of analysis itself. I think that only through careful examination can we decide the question as to which of these two points of view better reflects the actual situation.
My impression as a non-specialist of the problem is that nearly all the analytic schools that sought accreditation received it—including three Lacanian associations. The schools need only providing a common curriculum, but I don’t know what the criteria for such a curriculum are.
I think that getting caught up in the letter of the law makes us lose sight of what is essential: while the letter is important, the concrete meaning of a law depends on the actual society that applies it. What determines whether laws are good or bad are real relations of power and profound social demands: laws in themselves are rarely one or the other.
My feeling is that—apart from teratologic cases—laws, rather than being motors of change of actual social practices (and psychoanalysis is a widespread social practice) are instead signs or expressions of change or resistance, even symptoms in the analytic sense.
On the one hand, these legislative proposals respond to a social demand, regardless of whether it be valid or not; that is, they respond to an anxiety. It is precisely because people consider therapy a widespread practice (and no longer reserved only for an elite class) that anxiety arises: the State is asked to protect consumers from fraudulent analysts, “swindlers” and charlatans. Just as the State is increasingly called on to monitor and thus guarantee food safety (e.g., that product corresponds to the label), so, too, is it asked to assure the analysand-consumer that he is in the hands of someone who is in fact competent (even though most common people, just like politicians, haven’t the least idea as to what “competence” means in this case). I think that ignoring this social demand (anxiety) is a mistake: trying to avoid this demand for assurance by invoking the unfettered nature of an indescribable and unverifiable practice seems to me simply an expression of ideological purism. The State is pushed by social demand-anxiety to “act”, and we must take this into account whether we like it or not. The defense of our analytic freedom and autonomy cannot succeed if analysts ignore the demands of our society.
On the other hand, these regulations are also a sign of a growing need for “care of the self”—to quote Foucault’s terms—with the help of another. The increasing number of attempts at regulating psychotherapy—even though no one dares to regulate psychoanalysis, since it is too “aristocratic”—is the outcome of the social success of the modern form of care of the self: as the middle classes gain access to a treatment that was once reserved for a wealthy elite, they call on the intervention of the State, often only in order to gain access to such treatment. In the US, these pressures are directed towards private insurance companies; in Italy (and today in France) they’re directed towards the State, since Italy and France are more “Jacobin” (state-centered) countries. Psychotherapy is no exception to the rule: the democratization of a practice forces the welfare-state to intervene.
I don’t think that any thorough research has been carried out in Italy regarding suits against psychotherapists who are not legally recognized. For want of statistics, my comments are based on the accounts of expert friends who have followed these developments. My impression is that the vast majority of these suits are filed by the Order of Psychologists against individuals who practice while having (practically) no degree. Another impression—which may be mistaken—is that the Order usually loses the suits: there is a sort of network of analysts (where the presence of Lacanians is striking) who are presented as expert witnesses and who often succeed in convincing judges that psychoanalysis is not psychotherapy. If my impression is right, then the number of complaints filed by the Order should diminish over time. It also seems to me that the Order lodges complaints in somewhat extreme cases: against individuals who practice as so-called analysts with no university degree whatsoever.
As far as “patients” are concerned, unless they’re psychologists themselves, they don’t care about the official status of their analyst at all, for a very simple reason: they understand almost nothing of these distinctions which for us are so important. One typically creates one’s clientele through “word of mouth” or by way of the right connections (acquaintances among doctors, psychiatrists, priests, politicians, institutions, etc.): the analyst’s legal status becomes important only in certain cases when something needs to be made official. In short, “having official status” is more of a problem for the analyst than for the patient: it reduces the anxiety of the former rather than the latter. This is the paradox: while it was the anxiety of the public in general which brought about the Ossicini Act, it was actually the individual anxiety of the analysts which implemented it in the reality.
Most Italian analysts—as analysts, and not as psychologists or psychiatrists who also hold positions elsewhere—think that we were better off before the Ossicini Act. Clearly, as an analyst I share the same opinion. Yet, one must admit that the debate over regulation—one that’s still going on today, with a round-table meeting held in Milan in April 2004 regarding this issue, and whose proceedings are published here in English—has forced analysts to question themselves, even on the philosophical level, about their identity and the essence of their practice. Here, we keep discussing such topics as, “Can one identify the specifically analytic aspect of the cure in such a way that it be can be understood by colleagues from other schools or by a non-specialist public”? or, “What is the unique ethical aspect of an analytic action as different from a medical one”? At times, this heated debate reaches rather lofty levels. To the extent that laws have forced analysts to question their essence and their identity or difference, they have thus produced analytic effects. Based on our experience in Italy, I believe that the Accoyer legislative proposal—despite its potentially very negative effects—could be used by French analysts as an “analytic” opportunity in the broad sense, one not to be missed, for questioning themselves about the essence of the analytic act over and above institutional simplifications.
S. Benvenuto & O. Nicolaus (1990), eds., La bottega dell’anima. Problemi della formazione e della condizione professionale degli psicoterapeuti (Milan: Franco Angeli).