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. But if that doesn’t help and you have been feeling anxious or down for a long time, for instance, you can first go to your family doctor, a psychosocial information center, or or go straight to a psychotherapist or psychiatrist. Even if you aren’t sure whether you might need treatment for your own problems, you can get a first consultation there.

Initial consultation for psychological therapy: In Germany, practices for psychotherapy offer special initial consultations (in German: psychotherapeutische Sprechstunde). An initial consultation typically lasts 50 minutes, and serves to find out whether psychological treatment would be helpful or even urgently necessary. The practices must reserve a certain amount of their time for these consultations. You can schedule an appointment there either directly with the practice or through your Association of Statutory Health Insurance Physicians (in German: Kassenärztliche Vereinigung). You don’t need to get a note from a doctor or submit an application to your health insurer. One of these types of consultations should typically take place before you start with psychotherapeutic treatment. This consultation itself might also be regarded as one individual session. After that, adults typically have up to six sessions, and children up to ten, with each session lasting 25 minutes.

Acute treatment: In an emergency, you can go to a psychiatric practice with emergency services, an outpatient psychotherapy department, or a specialized psychiatric or psychosomatic clinic. Psychotherapeutic practices can also offer acute treatment without the need for an application to be submitted to your health insurer. For instance, it can started with the first appointment after your initial consultation. You have a right to acute treatment if the psychological problems could become more severe or chronic without the treatment, or if it is probable that you would be unable to work or would need to be hospitalized. Outpatient acute treatment involves up to 24 sessions of at least 25 minutes each (a total of 600 minutes).

Psychosocial counseling centers: specializing in e.g. family, women, childcare and addiction. The staff at these centers have various professional backgrounds. You might find, for example, doctors, social workers (in German: Sozialpädagogen and Sozialarbeiter), psychologists, psychotherapists, and 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 don't offer therapy themselves, but they can offer advice, provide information about support options, and initiate contact.

Social psychiatric services: Social psychiatric services are another point of contact. In Germany they are run by local health authorities and can be used for free. 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. These services generally don’t offer therapy themselves but can determine whether somebody needs treatment. They also offer extra support to people who are currently in therapy or have recently been in a clinic. You can also turn to social psychiatric services if you have the feeling that a family member, friend or coworker needs help, or you are finding it hard to cope with the mental illness of someone close to you. Where necessary the social psychiatric services also offer home visits.

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 of psychotherapy presented in films and other media. But there are lots of different kinds of psychotherapy that use very different approaches. The most common include behavioral therapy, depth psychology therapy and systemic (family) therapy. They are covered by statutory health insurance in Germany.

The goal of all types of psychotherapy 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 used to help people who are dealing with severe or 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. Certified psychologists have previously had to complete practically-oriented training as a psychotherapist lasting several years.

A separate course of study for psychotherapy was introduced in Germany in 2020, which will be the foundation for all work in psychotherapy in the future. Because this has only just started, all currently active therapists have completed their training in the older system. 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. In the future they will simply be called "psychotherapists" because that course of study will become the standard.
• Medical psychotherapists: They 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 mostly involved in treating mental illnesses where treatment with medication plays an important role, for example schizophrenia or severe depression. Because psychiatrists can also apply psychotherapeutic methods it’s 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.

Both groups of psychotherapists include therapists using depth psychology or analytic treatment approaches, as well as therapists working with behavioral or systemic therapy.

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 problems that young people have.

Previously, psychologists and specialists from the fields of social work or educational sciences were able to complete a course of study to become qualified therapists for children and teenagers. From now on, specialists can be trained as therapists for children and teenagers after completing a degree in psychotherapy.

Doctors can specialize in psychotherapy or psychiatry for young people 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:

• Appointment service centers of the Associations of Statutory Health Insurance Physicians
• Health insurers
• Psychosocial counseling centers
• Chambers of psychotherapists of the individual (German) federal states
• Medical associations of the individual (German) federal states
• Social psychiatric services

The appointment service centers of the Associations of Statutory Health Insurance Physicians are required to provide an appointment for an initial consultation within four weeks of your request. The maximum waiting time for a treatment appointment is reduced to two weeks if you need acute psychotherapeutic treatment.

Besides checking the telephone book, you can of course also use the internet. The Associations of Statutory Health Insurance Physicians, the chambers of psychotherapists and the medical associations all offer searches for a therapist by postal (zip) code.

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. Many practices also offer information on their own website.

It is perfectly normal and even important to ask specific questions before starting therapy. After all, therapy requires working together very closely and 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 insurers in Germany cover the costs for up to four trial sessions at a psychotherapy practice. Each session of therapy typically lasts 50 minutes. Appointment service centers of the Associations of Statutory Health Insurance Physicians can also help you schedule an appointment for trial sessions.

It usually becomes clear during the trial sessions whether you want to work together with that therapist. If not, it’s 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 explain 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 made for brief psychotherapy: No evaluation is needed to approve this kind of therapy that lasts a few sessions. The evaluator provides the healthy insurance company only 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, the health insurance company can cover the costs for psychotherapy.

However, statutory health insurers do not cover the costs for all types of psychotherapy. Practice-based psychotherapists can only bill certain types to the health insurers. The statutory health insurers in Germany currently recognize four approaches:

• Analytic psychotherapy
• Depth psychotherapy
• Behavioral therapy
• Systemic therapy

A wide variety of different methods can be used within these approaches. You can have group or individual therapy, or a combination of both. Group therapy involves groups of three to nine people.

Statutory health insurance also covers the costs of neuropsychological treatment. This type of treatment is needed if there has been organic damage to the nervous system that is causing psychological problems. This can result from a neurological condition like a stroke or after an accident.

Other types of psychotherapy can be provided and billed at psychiatric and psychosomatic clinics if an application with a specific reason is submitted.

It can take several weeks or months to start therapy at a psychotherapy practice. It's possible to get a first appointment for an initial consultation or acute treatment sooner. In very urgent cases you can contact the social psychiatric service, a psychosocial counseling information center, a psychiatric practice with an emergency service or a psychiatric or psychosomatic clinic.

One individual session (one "therapy hour") typically lasts 50 minutes. One group session usually lasts 100 minutes.

The total amount of time you need for psychotherapy depends on the type and severity of the illness and the therapy methods used. Therapy can be brief or long-term. Brief therapy includes a total of 24 therapy sessions. You apply for these sessions 12 at a time in two steps. If brief therapy isn't enough to treat the problems, an ongoing therapy can be switched to long-term therapy. This is also possible right after treatment begins if it becomes clear that long-term therapy would be helpful.

Statutory health insurers cover up to 48 therapy sessions for behavioral systemic therapy, up to 100 for depth psychology therapy and up to 300 for analytical psychotherapy. Insurers may be required to cover the costs for additional hours on a case-by-case basis.

The reason that systemic and behavioral therapy usually don’t last as long as analytic psychotherapy is that the goal of analytic psychotherapy is to develop a deeper understanding of your own problems and their relationships to your life history. That takes more time.

As it would be with a doctor or nurse, what you discuss with your therapist is kept confidential. Therapists are obliged to keep everything that is discussed during psychotherapy confidential. They are only allowed to share any of this information if you give your written consent. Therapists also aren’t allowed to record any sessions or phone calls without prior 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 or visit their website 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 support group.