What is psychotherapy and what does it involve?

Everyone feels a bit down, anxious, or distressed from time to time. That's a normal part of life and you usually feel better again after a while. But if it carries on for several weeks or more, and if it’s having a major impact on your daily life, psychotherapy can be a good idea.

Psychotherapy aims to reduce the problems caused by a mental illness and improve your quality of life. Psychotherapists use various methods to positively change the way you experience things and behave. Examples of areas in which they can help include:

• Gaining a better understanding of your own emotions and behavioral patterns
• Developing helpful behaviors
• Making better use of your own strengths
• Overcoming specific day-to-day difficulties

Psychotherapy can be used to treat mental disorders and illnesses such as:

• Anxiety disorders, like a generalized anxiety disorder
• Depression
• Obsessive compulsive disorder (OCD)
• Reactions to severe distress, like post-traumatic stress disorder (PTSD)
• Eating disorders, like anorexia or bulimia
• Addiction
• Personality disorders, like borderline personality disorder

But psychotherapy is not just used to treat mental health problems. It can also help people to cope with serious or chronic physical health issues. And it can be used to treat physical symptoms that are thought to be caused by mental health issues (known as a somatization disorder).

Psychotherapists can refuse to provide treatment if they believe that there is no need for treatment, or if psychotherapy does not seem appropriate.

Note: Some of the following information describes the situation in Germany specifically.

There are many different types of psychotherapy. The most commonly used ones in Germany are:

• Behavioral therapy (Verhaltenstherapie): The idea behind this type of therapy is that it’s possible to change negative behavior patterns because all behavior patterns are learned. It involves working with the therapist to analyze problematic behavior patterns and think about how you can change your behavior. You then practice behaving differently – often as “homework” between therapy sessions.
• Depth psychotherapy (Tiefenpsychologie): This approach is based on the assumption that problems you’re having today are the result of unresolved conflicts in the past. The aim is to revisit those conflicts and work through them.
• Systemic therapy (systemische Therapie): This approach focuses on social relationships – for example, with family members or at work. It is based on the belief that mental health problems are caused by dysfunctional interactions between a person and those around them (within their social "system"). The therapist helps them to understand relationship structures and to change any negative patterns. The other people in the relationships may also take part in the therapy.

Psychoanalytic therapy, which is where depth psychotherapy has its roots, is not very common nowadays. Like depth psychotherapy, it is based on the belief that mental illness is caused by repressed experiences in the past. But psychoanalytic therapy looks at the client’s underlying mental structure instead of specific conflicts.

There are a number of other types of therapy, including logotherapy, Gestalt therapy, and hypnotherapy. But unlike the four recognized types described above, they haven't been proven to work in good scientific studies.

A wide range of approaches can be used in each of these different types of therapy. The right kind of psychotherapy for you will depend on your specific mental health problem, your personal preferences and goals, and other factors.

Before you can start the actual psychotherapy treatment, you usually need to have an initial consultation with a psychotherapist (called psychotherapeutische Sprechstunde in German). During this consultation, the therapist determines whether you need psychotherapy. Adults can have up to six consultation sessions, and children and teenagers can have up to ten. Each session lasts 25 minutes but they can be combined to make 50-minute sessions.

Another aim of initial consultations is for the therapist to decide whether you need acute psychotherapy. Acute therapy is needed if your mental health problems could become more severe or chronic without it, or if you would probably have to stop working or go to a psychiatric hospital otherwise. You do not have to apply to your public health insurer for acute therapy. You can start it straight after an initial consultation. Outpatient acute therapy consists of up to 24 sessions of at least 25 minutes each (a total of 600 minutes). If necessary, it can be followed by another round of psychotherapy.

If you don’t need acute therapy, you’ll start off by having trial sessions – known as Probesitzungen or probatorische Sitzungen – after the initial consultation(s). Trial sessions usually last 50 minutes each. They give you a chance to get to know the therapist. This is important because the therapy won’t be effective if the chemistry isn't right. You need to be able to talk openly about your problems and difficulties. Not everybody finds a therapist they feel comfortable with straight away. Because of this, public (statutory) health insurers in Germany cover the costs of a certain number of trial sessions with a therapist: up to four sessions for adults and up to six for children and teenagers.

If you do feel comfortable with the therapist and you decide to stay with them, you fill in an application with them to be sent to your insurer. If the insurer approves the application, you can move on to actual treatment sessions.

You might decide during the initial consultations or the trial sessions that you don’t want to work with that therapist. If that happens, you can have trial sessions in another practice instead. The therapist doesn’t submit the application to the health insurer until you’ve made your decision.

Sometimes it doesn’t become clear that things aren’t working out with your chosen therapist until you’ve had a few actual therapy sessions. If that happens, you can continue the therapy in a different practice. Your health insurance company will tell you if you need to re-apply.

Once you’ve had the trial sessions, you’ll need to fill in an application with the therapist. They have to provide an explanation of why therapy is necessary.

You'll also need to include a doctor's report for your public health insurer. The therapist will refer you to a family doctor or specialist doctor to get the report. Before writing the report (known as a Konsiliarbericht), the doctor will give you a general physical examination. In the report, they state whether the mental health issues are possibly being caused by physical health factors, whether you need medical treatment in addition to the therapy, and whether there are any reasons why you shouldn't have therapy. The doctor’s report is submitted to the health insurer along with the therapy application before the actual psychotherapy sessions start.

Public health insurers decide whether to approve psychotherapy 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 the planned psychotherapy is appropriate. The insurer typically follows the evaluator’s recommendation. If the insurer approves the therapy, they’ll cover the costs.

The rules are different for short-term psychotherapy (Kurzzeittherapie). This sort of therapy consists of fewer sessions and can be approved without the need for an evaluation.

Private health insurers have different rules when deciding whether to cover the costs of psychotherapy. If you have private health insurance, contact your insurer to ask about this.

Public insurers generally cover the costs of psychotherapy for all mental illnesses and disorders that are considered to need treatment. It is also possible to have psychotherapy costs covered when a physical illness like tinnitus or cancer is causing a lot of psychological distress.

But public health insurers don’t pay for all types of psychotherapy. Practice-based psychotherapists can only bill public health insurers for the following approaches:

• Psychoanalytic therapy
• Depth psychotherapy
• Behavioral therapy
• Systemic therapy

It is not possible to combine the different types of therapy.

The therapy can take place in a group, in one-on-one sessions, or a mixture of both. Therapy groups are made up of 3 to 9 people. Larger groups, with up to 14 people, are also possible. Then they are run by two therapists. Online therapy sessions using video calls are sometimes possible too (both for individuals and groups).

Public health insurance also covers the costs of neuropsychological treatment. This type of treatment is needed if mental health problems are being caused by physical damage to the nervous system – for example, after a stroke or an accident. It can only be provided by qualified neuropsychologists.

A one-on-one session typically lasts 50 minutes. One group session usually lasts 100 minutes.

The amount of time you need to complete psychotherapy depends on the type and severity of your illness and the type of therapy. There is short-term and long-term therapy. Short-term therapy includes up to 24 sessions. You apply for these sessions 12 at a time, in two steps. If you complete short-term therapy and it wasn't enough to treat the problems, it can be extended to become long-term therapy. This is also possible during short-term therapy if it becomes clear that long-term therapy would be more helpful. You have until the 20th session to apply to switch from short-term to long-term therapy.

German public health insurers cover the costs of therapy for the following number of sessions:

• Systemic therapy: up to 48 sessions
• Behavioral therapy: up to 80 sessions
• Depth psychotherapy: up to 100 sessions
• Psychoanalytic therapy: up to 300 sessions

They may also cover the costs of more sessions on a case-by-case basis.

Systemic and behavioral therapy tend to take a shorter amount of time than psychoanalytic therapy. The reason for this is that psychoanalytic therapy aims to help the person develop a deeper understanding of their problems and how they link in with other things in their past. That takes more time.

Your therapist has to keep anything you tell them confidential, just like doctors and nurses do. They’re only allowed to share what you have told them if you give your written consent. Therapists aren’t allowed to record any sessions or phone calls without asking you first, either.

Like doctors, psychotherapists are required to keep a written record of all the treatments they give. Clients have the right to see those records.