Psychotherapy in Germany

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Psychotherapy in Germany is a healing activity to determine, cure or alleviate mental disorders with disease value. Professionally, it may only be carried out by medical psychotherapists , psychological psychotherapists , child and adolescent psychotherapists and alternative practitioners for psychotherapy .

definition

Psychotherapy is a form of medicine in Germany . It may only be exercised by persons who are authorized to do so. Unauthorized practice of psychotherapy is a punishable offense ( § 5 HeilPrG). Psychological activities that do not deal with medicine , in particular dealing with and overcoming social conflicts, do not count as practicing psychotherapy ( Section 1, Paragraph 3, Sentence 3, PsychThG).

The definition of what is to be understood under professional law by psychotherapy is regulated in Germany in the Psychotherapists Act and the Heilpraktikergesetz.

  • According to Section 1 Paragraph 3 Clause 1 PsychThG, psychotherapy within the meaning of the Psychotherapists Act is “detection, cure or alleviation of disorders with disease value for which psychotherapy is indicated” “using scientifically recognized psychotherapeutic procedures”.
  • According to § 1 Para. 1 HeilprG, medicine is the "determination, healing or alleviation of illnesses, suffering or physical harm in people".

The definition of the Psychotherapists Act of 1999 is based on the definition of the term medicine from 1939, but the term medicine of the Heilpraktikergesetz does not require the scientific recognition of a treatment method. The Psychotherapists Act "neither restricts the medical powers of doctors nor the rights granted by a permit under the Heilpraktikergesetz [...]". This means that the scientific recognition of a psychotherapeutic procedure is not a requirement that a psychotherapy procedure generally has to meet in order to be considered psychotherapy or to be permitted, but the characteristic represents a condition to be allowed to practice psychotherapy in accordance with an approval of the Psychotherapists Act (i.e. as a psychological psychotherapist or child and adolescent psychotherapist).

Legal basis

Professional law

In Germany, depending on the permit, a distinction must be made between four groups of authorized persons who are allowed to practice psychotherapy. Each group has different legal requirements, which result in different training standards as well as different treatment limits and options.

  • Medical psychotherapist . Medical psychotherapists practice psychotherapeutic medicine in accordance with Section 1 Paragraph 1 HeilprG on the basis of their medical license in accordance with Section 2 Paragraph 2 BÄO and several years of further training in psychotherapy. You can call yourself a psychotherapist ( Section 1, Paragraph 1, Sentence 4, PsychThG). Your psychotherapy must be based on the current state of scientific knowledge, but is not restricted to scientifically recognized procedures under professional law and can claim more freedom of therapy than psychotherapy, which is possible on the basis of the Psychotherapists Act. As a doctor, you are generally allowed to clarify somatic causes of mental disorders yourself and, in addition to psychotherapy, you can also use other medical procedures, in particular medication, for treatment. - Training path: After completing their medical studies, doctors train themselves either to become a “specialist in psychosomatic medicine and psychotherapy”, a “specialist in psychiatry and psychotherapy” (often in combination with the “specialist in neurology ”) or specialist in child and adolescent psychiatry and psychotherapy further, or they acquire - after any (non-psychotherapy-related) specialization or specialist training - additionally the additional qualifications "Psychotherapy" or "Psychoanalysis".
  • Psychological psychotherapist and child and adolescent psychotherapist . Members of these two health professions practice psychotherapy on the basis of their license to practice medicine in accordance with Section 1, Paragraph 1, Sentence 1 of the PsychThG. You can call yourself a psychotherapist ( Section 1, Paragraph 1, Sentence 4, PsychThG). They cannot clarify possible physical causes of mental disorders themselves ( Section 1, Paragraph 3, Sentence 2, PsychThG). They are also notauthorizedto prescribe medication ( pharmacotherapy ). In addition, you may only use psychotherapeutic procedures that are scientifically recognized ( Section 1, Paragraph 3, Sentence 1, PsychThG). Only psychotherapy procedures whose effectiveness has been proven can be considered scientifically recognized. The decision on this is made by the competent state authority ( Section 10 PsychThG). In cases of doubt, it should make its decision on the basis of an opinion from the Scientific Advisory Board on Psychotherapy ( Section 11 PsychThG). The advisory board's reports represent anticipated expert reports, the results of which must be followed, unless “the viability of its assumptions must be called into question in principle,” for example because the content is scientifically outdated. - Training path: Psychological psychotherapists have a degree in psychology (diploma or master's) with a focus on clinical psychology in their main course. Furthermore, they have several years of in-depth training in a scientifically recognized therapy method. Child and adolescent psychotherapists have a degree in psychology (diploma or master), medicine, pedagogy (diploma or master) or social pedagogy (diploma or master). After graduation, analogous to the psychological psychotherapists, there is a multi-year specialist training with subsequent license to practice medicine.
  • Naturopath . Non-medical practitioners with a general medical license in accordance with § 1 Paragraph 1 HeilprG are allowed to practice psychotherapy. However, you are not allowed to call yourself a psychotherapist ( Section 1, Paragraph 1, Sentence 4, PsychThG). By successfully passing the alternative practitioner examination, you have provided evidence that you have sufficient knowledge to be able to carry out psychotherapy on your own responsibility without posing a risk to public health. You have freedom of therapy and are allowed to use all psychotherapy procedures, i.e. scientifically recognized and scientifically unrecognized, without proof of a training standard that has been achieved. The interest in patient protection is legally safeguarded by the fact that the state has convinced itself through the alternative practitioner examination that alternative practitioners pose no danger to patients by practicing psychotherapeutic medicine. Within the limits of their powers of alternative practitioners (with regard to the doctors), they are generally allowed to clarify physical causes of mental disorders themselves and, in addition to psychotherapy, are also allowed to use other methods to treat mental disorders. - You will receive the medical license by way of an official medical examination by the responsible health department. The training paths of alternative practitioners are not regulated by the state. They usually prepare for their work with the help of non-governmental training institutions, for example through a course at a private institute.
  • Non-medical practitioners, restricted to the field of psychotherapy, practice psychotherapy on the basis of a medical permit limited to psychotherapy in accordance with Section 1 (1) HeilprG. You are not allowed to call yourself a psychotherapist ( Section 1, Paragraph 1, Sentence 4, PsychThG). The same applies to them as to alternative practitioners, with the exception that they are only allowed to use psychotherapy as a treatment method and are not allowed to clarify possible physical causes of mental illness themselves. - As alternative practitioners, restricted to the field of psychotherapy, psychologists can also practice who have completed a degree in psychology with a diploma or Master of Science, but have not obtained a license to practice medicine under the Psychotherapists Act. If they had “clinical psychology” as an examination subject for their university degree, they will be granted a restricted alternative practitioner permit based on the files upon request. Otherwise, like all other candidates, they have to pass the appropriate alternative practitioner examination.

In February 2019, the Federal Cabinet passed a draft law to reform psychotherapist training (PsychThGAusbRefG). The law is subject to approval in the Federal Council. A five-year university course is planned in the form of a three-year bachelor's degree and a two-year master's degree, which is concluded with a state psychotherapeutic examination. After passing the exam, the license to practice as a psychotherapist is granted. Subsequent further training - similar to that for doctors - should be required for access to the statutory health insurance system.

Social law

The statutory health insurance and thus also its procedure with regard to psychotherapy is regulated in the fifth book of the Social Security Code ( SGB ​​V ). Section 92 stipulates that the so-called Federal Joint Committee adopts "Guidelines on the granting of adequate, appropriate and economic provision for the insured". These guidelines regulate in particular for psychotherapy:

  • diseases requiring treatment
  • Appropriate procedures for treating illness
  • Application and review process
  • probatory sessions
  • Type, scope and implementation of the treatment as well as the medical consultant report

Services can be restricted or excluded "if, according to the generally accepted state of medical knowledge, the diagnostic or therapeutic benefit, the medical necessity or the economic viability have not been proven".

The social psychiatry agreement enables specialists in child and adolescent psychiatry and psychotherapy to carry out psychotherapeutic programs in cooperation with unapproved and licensed therapists in a multi-professional team who are not subject to the expert application procedure. This widespread and modern form of child psychotherapeutic treatment is also called multimodal child therapy . In the adult sector in Germany there is currently no comparable basis under social insurance law for multimodal psychotherapeutic treatment in an interdisciplinary team.

The conditions of private health insurance are different. Basically, they are based on the legal procedures, but often have somewhat more generous regulations in individual cases, for example with practitioners and therapeutic procedures. Before starting therapy, however, written consent must usually be obtained from the insurance company.

Diseases

The first requirement for psychotherapy according to the psychotherapy guidelines is that there is a mental illness. This is, also in delimitation z. B. on mood disorders, clearly defined in the "Commentary on psychotherapy guidelines".

Therapy procedure

So far, the reimbursement of outpatient psychotherapy has been limited to four therapy methods:

In the meantime, conversational psychotherapy (for adults) and systemic therapy for children and adolescents are also scientifically recognized by the Scientific Advisory Board on Psychotherapy . Treatment with counseling psychotherapy is currently still not paid for by the statutory health insurances. The social law recognition required for this by the Federal Joint Committee of Doctors and Health Insurance Funds, which is a prerequisite for reimbursement, is still pending.

Practitioner

The service providers of psychotherapy in the statutory health insurance system are psychotherapists approved as contract physicians or psychotherapists in the statutory health insurance. A professional license (license to practice medicine) is a prerequisite for this approval . Psychological psychotherapists and child and adolescent psychotherapists are on an equal footing with appropriately qualified specialists. There is freedom of choice for the patient.

In the event of a presumed psychotherapy undersupply, a professionally qualified licensed psychotherapist or HP psychotherapy can provide non-contractual psychotherapy at the expense of the statutory health insurance in individual cases, even without a health insurance license; In such cases, the medical service of the health insurance is usually consulted by the health insurance company in advance , but it only has to decide whether psychotherapeutic treatment is indicated and whether the specified psychotherapy procedure complies with the guidelines of the Federal Committee.

Duties

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Supplementary note: Conversations by resident colleagues with mentally ill people who have the above Criteria do not meet and the z. B. are provided in the context of basic psychosomatic care, have a supportive function or initiate further therapy (e.g. psychotherapy). They cannot replace psychotherapy.

According to Section 95d SGB V, there is an obligation for resident colleagues to undertake continuous further training (acquisition of currently 250 CME points in five years), otherwise there is a risk of fee deduction or, in the next step, withdrawal of approval by the responsible health insurance company. In the field of psychotherapy, the prescribed expert procedure is a quality assurance measure.

The economic efficiency requirement stipulated in § 12 SGB V already implies that a service provided at the expense of the statutory health insurance must be of sufficient quality; otherwise their provision would not be appropriate, insufficient and consequently uneconomical. Sections 73c, 135a, 136, 136a and 136b SGB V and Section 11 of the Federal Ministry of Transport and Digital Infrastructure regulate quality assurance in the area of ​​statutory health insurance - although kept quite general. There is an obligation to set up a quality management system in practice, but no obligation to obtain a certificate, ie confirmation of quality by qualified third parties.

Application and review process

Further prerequisites for psychotherapy are the patient's ability to psychotherapy (the patient must be intellectually and motivationally able to benefit from psychotherapy) and the availability of adequate diagnostics and an appropriate treatment plan. Unlike other procedures in the field of statutory health insurance, long-term therapy, e.g. In some cases, quality assurance has also been implemented in short-term therapy for inexperienced therapists through an upstream expert review procedure (application process). Every long-term therapy requires an application from the patient with a report to be drawn up by the therapist to the expert , in which the anamnesis, diagnosis, recovery model, detailed therapy planning and prognostic assessment of the patient's individual chances of recovery are listed. The application and the report will be checked by a qualified external medical or psychological expert who is himself a psychotherapist. Costs can only be covered by the statutory health insurance after the expert's approval (see also Section 11, Appendix 1 to the federal collective bargaining agreement).

Trial sessions, type, scope and implementation of the treatment

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Both individual therapy and group therapy are possible in the outpatient area. Billing takes place using the uniform evaluation standard .

The time quotas for psychotherapy are fixed. After five (behavioral therapy and psychotherapy based on depth psychology) or eight (analytical psychotherapy) trial sessions , which serve to check the indications, short-term therapy of up to 25 hours can be carried out. In the case of non-medical therapists, a medical consultation report is also required before the start of therapy. a. certifies the absence of a physical illness and clarifies any questions about taking medication. If there is a need for longer therapy, long-term therapy can be used (short-term therapy can be converted into long-term therapy on request). The maximum limits for long-term therapies are for adults (for children and adolescents there are slightly lower numbers of hours):

  • In the case of behavioral therapy up to 45 hours, in individual cases it is extended to 60 hours after justification.
  • for analytical psychotherapy up to 160 hours, in special cases up to 240 hours.
  • in the case of psychotherapy based on depth psychology, up to 50 hours, in special cases up to 80 hours.

In justified individual cases, these times can be exceeded

  • for behavior therapy for 80 hours, in individual cases with a further request for 100 hours,
  • for analytical psychotherapy up to 300 hours,
  • up to 100 hours for psychotherapy based on depth psychology.

Psychotherapeutic care

According to a study published in 2011 by the Federal Chamber of Psychotherapists, the average waiting time in outpatient psychotherapeutic care is 12.5 weeks for an initial consultation. There are regional peculiarities. In the country, the waiting time is just under four months. In the Ruhr area and in the eastern German federal states, the supply is rated as particularly poor.

A Forsa survey of 1,000 parents of school-age children commissioned by Techniker Krankenkasse showed that at least one in ten children received psychotherapy. 60 percent of the children treated were girls.

Health economic aspects

In Germany, psychotherapy is used by a considerable number of the 27,000 licensed psychologists and 23,000 specialists and general practitioners with further training in psychotherapy. Every year around 900 million euros are distributed to psychological psychotherapists via the KV system, i.e. within the framework of the statutory health insurance . The 250 German university professorships in the "P" subjects cost around 60 million euros a year. Inpatient psychiatry, within which a lot of psychotherapy also takes place, costs 4 billion, inpatient rehabilitation 0.5 billion, psychosomatic hospital treatment 0.2 billion, outpatient psychiatric treatment 0.5 billion and guideline psychotherapy around 1.5 billion, together around 6 Billion euro.

Consumer protection

In the case of therapy within the framework of statutory health insurance, up to five (for deep psychological PT and behavioral therapy) or eight (for analytical PT) trial sessions ("trial sessions") per psychotherapist are possible in order to check whether a sustainable working relationship can be established . The costs and duration of the therapy as well as the other framework conditions should be coordinated. Only after this phase, in which the therapy goals and the treatment plan are discussed, an application for psychotherapy is made and the actual therapy begins. A hasty or wrong decision for a therapy place can also exacerbate the original problem. If the therapy is discontinued, the approval of subsequent therapy by the health insurance company may be questioned.

If a treatment error is suspected, psychotherapy clients who feel harmed by a therapy can contact the patient advice center at a consumer advice center. There you will receive an assessment from a legal point of view as well as advice on how to deal with the consequences of what you consider to be an unsuccessful therapy.

Individual evidence

  1. ↑ BVerwG, judgment of February 10, 1983 - 3 C 21/82 = BVerwGE 66, 367 = NJW 1983 pp. 1414–1416
  2. ↑ The regulation also applies to psychological psychotherapists and child and adolescent psychotherapists if they carry out medical activities that are not regulated by the Psychotherapists Act. BT-Drucksache 13/1206, S. 14, RdNr. 10.
  3. ↑ BT-Drucksache 13/1206, S. 14, RdNr. 10
  4. ↑ Compare BVerwG 3 C 4.08 - judgment of April 30, 2009, No. 13 (with an explicit distinction between the academic qualification requirements for psychotherapy based on the Psychotherapists Act and any qualification requirements for psychotherapy based on the Heilpraktikergesetz) and No. 14th
  5. ↑ BVerwG 3 C 4.08 - judgment of April 30, 2009, No. 18th
  6. ↑ Berlin Chamber of Psychotherapists: Training Regulations. Psychotherapeutenkammer Berlin - training regulations
  7. ↑ BVerwG 3 C 4.08 - judgment of April 30, 2009, first guideline, as well as No. 10-13
  8. ↑ BVerwG 3 C 4.08 - judgment of April 30, 2009, third principle, as well as No. 24-27
  9. ↑ BVerwG 3 C 34.90 of January 21, 1993, No. 24; BVerwG, judgment of February 10, 1983 - 3 C 21/82 = BVerwGE 66, 367 = NJW 1983 pp. 1414–1416
  10. ↑ BVerwG, judgment of February 10, 1983 - 3 C 21/82 = BVerwGE 66, 367 = NJW 1983 pp. 1414–1416; BVerwG 3 C 4.08 - judgment of April 30, 2009, No. 13
  11. ↑ BVerwG, judgment of February 10, 1983 - 3 C 21/82 = BVerwGE 66, 367 = NJW 1983 pp. 1414–1416; BVerwG 3 C 19.08 of August 26, 2009, No. 22nd
  12. ↑ BVerwG 3 C 34.90, January 21, 1993, 3rd principle
  13. ↑ BVerwG 3 C 34.90 of January 21, 1993, No. 27
  14. ↑ Cabinet resolves training reform. In: ÄrzteZeitung. February 28, 2019, accessed July 16, 2019 .
  15. ↑ Modern training for psychotherapists. In: www.bundesgesundheitsministerium.de. May 9, 2019, accessed July 16, 2019 .
  16. ↑ Social psychiatry agreement kbv.de (PDF)
  17. ↑ https://www.g-ba.de/downloads/62-492-958/PT-RL_2014-10-16_iK-2015-01-03.pdf
  18. ^ Rüger, U., Dahm, A. & Kallinke, D. (2011). Faber / hair knitting. Comment psychotherapy guidelines. Munich: Urban & Fischer. (9th ed.)
  19. ↑ Psychotherapy Guideline of the Federal Joint Committee in the version of February 19, 2009, last amended on October 15, 2015 (accessed on April 21, 2016; PDF; 139 kB)
  20. ^ Procedures of psychotherapy in the statutory health insurance
  21. ↑ Press releases - Federal Joint Committee. Retrieved June 3, 2020 .
  22. ^ Scientific Advisory Board for Psychotherapy (according to § 11 PsychThG): Expert opinion on the subsequent application for conversation psychotherapy from September 16, 2002.
  23. ^ Opinion of the Scientific Advisory Board for Psychotherapy on Systemic Therapy from December 14, 2008 systemische-gesellschaft.de (PDF)
  24. ↑ Press release of IDW for systemic therapy of 8 January 2009 (accessed on May 8, 2012)
  25. ↑ BPtK study on wart times in outpatient psychotherapeutic care (PDF; 1.8 MB)
  26. ↑ MMW-Fortschr.Med. No. 9/2010 (152 vol.), P. 8
  27. ↑ Figures quoted from Loew, Psychodynamische Psychotherapie (PDP) 2009; 8:57
  28. ↑ Far away from sick mind, Doctors newspaper, July 3, 2008, p. 5
  29. ↑ a b Psychodynamic Psychotherapy (PDP) 2009; 8:57