A guide to psychotherapy in Germany: Where can I find help?

Many people turn to their friends and family first if they don't feel well. People who need professional help for psychological problems can first talk to their family doctor, a psychosocial counselor or go straight to a psychotherapist or psychiatrist. In an emergency there are also psychiatric practices with emergency services as well as psychiatric clinics.

Psychosocial counseling centers offer help for a variety of issues, including family, women, childcare and addiction. The staff at such centers have different professional backgrounds. You might find, for example, doctors, social workers (in German: Sozialpädagogen and Sozialarbeiter), psychologists, psychotherapists, as well as specially trained care workers all working together to help people solve their problems. The counseling centers are usually funded by supporting organizations, subsidies and donations. They do not offer therapy themselves, but they can offer advice, information about support options, and initiate contact.

Social psychiatric services are another point of contact. In Germany they are run by local health authorities and can be used for free by everybody. They particularly support people who need treatment for acute or chronic mental illnesses. The social psychiatric service teams are also made up of doctors, care workers, psychotherapists and social workers. The centers generally do not offer therapy themselves but can determine whether somebody requires treatment. They also offer extra support to people who are currently in therapy or have recently been in a clinic. Family, friends and colleagues can also contact the social psychiatric service if they have the feeling that somebody they know needs help. Where necessary the social psychiatric services also offer home visits.

Just like therapists, the staff at the social psychiatric services and psychosocial counseling centers are obliged to maintain patient confidentiality.

When people hear the word "psychotherapy" they might think of somebody lying on a couch talking about their childhood while the therapist is sitting in the chair next to them listening. This is a common image that we see of psychotherapy in films and other media. But there are lots of different kinds of psychotherapy that use very different approaches. The most commonly used methods are cognitive behavioral therapy and depth psychology therapy.

The goal of all psychotherapies is to relieve the symptoms caused by the mental illness and improve quality of life. The question as to which method is suitable depends on many aspects, including the type of problem or illness as well as the preferences and personal goals of the person who needs therapy.

The most common mental illnesses and disorders that are treated with psychotherapy include anxiety disorders, depression and addiction. By the way, psychotherapy is not just used to treat mental conditions: It is also an option for people who are dealing with chronic physical illnesses. Psychotherapists can also refuse to provide treatment if they believe that there is no need for therapy, or if psychotherapy does not seem appropriate.

There are various professional titles in the area of psychotherapy in Germany, and they can be quite confusing. For example, many people think that psychologists and psychotherapists are the same thing. But just because somebody has a degree in psychology does not mean that they can automatically offer therapy. To be able to do so psychologists first have to complete several years of practical psychotherapy training and then pass a state examination.

Here is an overview of the various categories and titles:

• Psychological psychotherapists: Psychologists with psychotherapy training. They treat conditions such as anxiety disorder, depression and other mental illnesses in a therapeutic practice. Unlike medical psychotherapists, they are not allowed to prescribe medication.
• Medical psychotherapists: They also have to have an additional qualification in psychotherapy or corresponding special training before they may work as a psychotherapist. Each federal state has its own qualification regulations. Most medical psychotherapists have completed further training to become a specialist for psychiatry or psychotherapy.
• Psychiatrists: These specialists are particularly concerned with treating mental conditions where treatment with medication plays an important role, for example schizophrenia or severe depression. Because psychiatrists can also apply psychotherapeutic methods it is difficult to make a clear distinction between psychiatry and medical psychotherapy.
• Specialists for psychosomatic medicine and psychotherapy: Doctors with this specialist qualification primarily treat physical conditions that are thought to be caused or affected by mental issues.
• Specialist doctors with psychotherapy training: These doctors, who have an additional psychotherapy qualification, only treat mental illnesses or disorders that are to do with their area of medical expertise. They could for example include gynecologists who offer women with breast cancer extra psychotherapy support.

A major difference between the two professions is that medical psychotherapists can also prescribe medication for the treatment of psychological illnesses ( psychotropic drugs). On the other hand, psychological psychotherapists work only with conversational therapies, psychological methods, relaxation techniques and other non-pharmaceutical approaches. If someone is getting therapy from a psychologist and also needs medication, the medication can be prescribed by a doctor. Ideally medical and psychological psychotherapists should work closely together.

Most medical psychotherapists use depth psychology or psychoanalytical treatment methods. Comparatively few are behavioral therapists, although that number is increasing. Around half of all psychological psychotherapists are trained in behavioral therapy, the other half in depth-psychological methods.

Mental illnesses that occur during childhood and teenage years can be different from those that adults experience. Treatment is sometimes different too. That is why some psychotherapists specialize in the mental problems that young people have.

As well as psychologists, social workers can also train to become psychotherapists for children and teenagers. Doctors can specialize in psychotherapy or psychiatry for adolescents by completing a residency in child and youth psychiatry and psychotherapy. Medical psychotherapists and pediatricians can also complete an additional qualification in the psychotherapeutic treatment of children and teenagers.

There are various places that can help you find a psychotherapist or psychiatrist, for example:

• Your health insurer
• Psychosocial counseling centers
• Regional psychotherapist and medical associations
• Social psychiatric services

Along with looking in the telephone book, you can of course also use the internet. For example, statutory health insurance associations offer a doctor and psychotherapist search function. Most of the psychotherapist associations in Germany also offer a search service.

There is no need to be reluctant about contacting the practice if you are interested in a particular approach or want to find out more about the therapist, for example how long they have been in the profession and what their specialist areas are. It is totally normal and important to ask specific questions before starting therapy. After all, the therapist and the patient have to work very closely together on a very personal basis.

Other questions the patient might ask include:

• Do you have experience with people who have a similar condition to mine?
• Which therapy approach or which medication can help with my illness?
• What possible side effects could the therapies have?
• How long do the suitable psychotherapy methods last and how often would I have to come to the practice?
• What might happen if I do not get therapy? Would it be enough to seek help elsewhere, for example at a psychosocial counseling center?

It is essential that there is a relationship based on trust between the patient and the therapist. It is important and has to be possible to talk completely openly with the therapist about problems and difficulties. Not everybody finds someone they feel comfortable with straight away. That is why statutory insurance companies in Germany cover the costs for up to four trial sessions at a psychotherapy practice.

It usually becomes clear during the trial sessions whether you want to work together with that therapist. If not, it is possible to have further trial sessions in another practice. Only once you have decided to continue therapy with a particular therapist do they have to apply for approval from the client's insurance company.

If during the course of the therapy it becomes apparent that things are not working out so well with the therapist, it is still possible to continue therapy at another practice. Your health insurance company will tell you if you need to make a new application.

The patient and therapist have to make an application for therapy together after the trial sessions. The therapist has to state why therapy is necessary. Along with the application for therapy, the statutory health insurance company also requires a doctor's report. A practicing doctor can provide that after a general examination. The report is a guarantee that the symptoms are not caused by physical problems and that there are no reasons why psychotherapy should not be performed. The application for therapy has to be submitted to the statutory health insurance company together with the doctor's report before therapy can begin.

The statutory health insurer decides whether to approve therapy based on an evaluation. An evaluator with special training assesses the application and the doctor's report, which remain anonymous to them, to decide whether psychotherapy is appropriate. If so, the insurer will cover the costs. An exception is brief psychotherapy: No evaluation is needed to approve this kind of therapy that only requires a few sessions. The evaluator only provides the healthy insurance company with the information needed for payment of the therapy.

The conditions for private insurers covering therapy costs can vary. Privately insured people should ask their insurer about the standard procedure.

As a general rule, statutory insurers cover the costs for psychotherapy for all mental illnesses and disorders that are considered to need treatment. Also if a physical illness causes considerable psychological strain, for example tinnitus or cancer, which are often accompanied by depression, the health insurance company can cover the costs for psychotherapy.

However, statutory health insurers do not cover the costs for all types of psychotherapy. There are currently three approaches that are approved:

• Analytical psychotherapy
• Depth psychology therapy
• Behavioral therapy

A wide variety of different approaches can be used within these three approaches.

It can take several weeks or months to start therapy at a psychotherapeutic practice. However, you can generally make a first appointment to find out whether you have a mental illness at shorter notice. In urgent cases you can contact the social psychiatric service, a psychosocial counseling center, a psychiatric practice with an emergency service or a psychiatric hospital.

The amount of time you need for psychotherapy depends on the type and severity of the illness and the therapy methods used. Statutory health insurers cover up to 80 therapy sessions for behavioral therapy, up to 100 for depth psychology therapy and up to 300 for analytical therapy. Insurers may be required to cover the costs for additional hours on a case-by-case basis. Double sessions are also possible as part of group therapy sessions.

The fact that behavioral therapy does not last as long as analytical psychotherapy is due to behavioral therapy being a more practically oriented method that is primarily concerned with solving specific problems. Analytical psychotherapy, on the other hand, aims to develop a deeper understanding for the patient's problems and how they link in with other things in their past.

Just like doctors and nurses, psychotherapists are required to maintain confidentiality. They are obliged to keep everything they are told by their clients during psychotherapy confidential. Psychotherapists are only allowed to pass on information if the client has previously given their written consent. They are also not allowed to record any sessions or telephone conversations without the client's consent. And like doctors, psychotherapists are required to make a written record of all treatments they have given.

Some people find it difficult to seek help with their problems from a psychotherapist. There can be different reasons for that. Some people are scared of being labeled mentally ill or they are reluctant because they don't know what happens during psychotherapy. Others doubt whether psychotherapy can really help them. Yet people who have started or completed therapy say they regret not having sought help earlier. It is not easy to challenge and change your own thoughts and ways of behaving – it can actually be very stressful and demanding. But very often the effort is worth it: Successfully getting over depression or a compulsive or anxiety disorder considerably improves quality of life.

If you find it difficult to go to therapy, you could try one of the following things:

• First take a walk and have a look at the building where the practice is – it is often helpful to get an impression of the surroundings.
• Call a psychotherapy practice anonymously and find out what the therapy they offer typically involves.
• Look for a psychotherapy practice in a different area, further away from your home.
• Ask a friend or family member to go to the first appointment with you.
• Talk to other people who have had similar therapy in the past, for example by contacting a self-help group.