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In what follows I would like to give you some general information about psychotherapeutic care in Germany. This information will answer the most frequently asked questions about psychotherapy while giving you an overview of its most common methods.
Is psychotherapy generally paid for by insurance?
When arranging an appointment I am frequently asked whether, as a rule, health insurance pays for psychotherapy. In Germany we are in the fortunate position of having psychotherapy services covered by both private and statutory insurance companies. However, certain conditions must be met in order that psychotherapy services be covered by insurance.
The therapist – as a rule a medical doctor or psychologist – must for example have certain qualifications. Following the study of medicine or psychology and respective certification, it is necessary to complete a course of further training in psychotherapy that generally lasts three to six years. The scope and duration of this training is hereby precisely prescribed by law. State-approved institutions are usually charged with implementing the training, while chambers of physicians and psychotherapists verify that the doctor or psychologist has fulfilled the training criteria. Since 1999, the term “psychotherapist” has been legally protected in Germany so that the standard of quality is assured. Only certified physicians and psychologists who have completed this advanced training are allowed to adopt the professional designation “psychotherapist.”
For many years, I have been treating English-speaking and foreign patients who are not insured by German health insurance companies. Due to my education and qualifications, most foreign-based private health care companies (like Cigna, Blue Shield / Blue Cross etc) generally take on the cost of treatment.
What forms of psychotherapy are there?
There are many forms of therapy, some with lovely-sounding names, that promise to heal or relieve psychological problems. Many of these therapies are however lacking a scientific foundation, and their postulated working mechanisms are based in part on esoteric worldviews and more or less dubious theories; or they promise miracle cures in just a few sessions.
Without wishing to dispute the support or short-term psychological relief that can sometimes subjectively be experienced through these forms of psychotherapy, none of them has yet been able to withstand scientific scrutiny. That is why there are currently only three methods of psychotherapy covered by private and statutory health insurers: these three methods have for decades been able to demonstrate scientifically their effectiveness in treating psychological illness.
These three methods are:
-analytical psychotherapy (psychoanalysis)
Following my medical studies, I myself worked as an assistant physician of internal medicine; in psychiatry; and in a rural general practice. For a total of six years, in addition to and alongside my work, I was trained in two of the three above-listed psychotherapy methods, namely: depth-psychology-based psychotherapy and analytical therapy (psychoanalysis). The Chamber of Physicians awarded me the designation "Depth-Psychology-Based-Psychotherapist" in 1995 and "Psychoanalyst" in 1999.
What is the difference between these individual forms of therapy?
Depth-Psychology-Based Psychotherapy and Analytical Psychotherapy (Psychoanalysis)
Depth-psychology-based psychotherapy and analytical psychotherapy (psychoanalysis) postulate that a kind of “unconscious software” underlies the symptoms of illness – be they fears, depression, self-esteem problems or physical problems. On the basis of their experiences and observations (above all during their childhood and youth), human beings unconsciously write numerous "software modules." These accompany them throughout their lives and concern, for example, their dealings with others, their own self-worth, or the processing of guilt and aggression. Present life events such as a new boss, a new relationship, the birth of children, experiences of loss, and hurtful or traumatic events can cause old software modules unconsciously to be “uploaded.” This recourse to old software modules is, however, frequently an inadequate or unfortunate attempt at a solution, and the course of unconscious processes can lead to psychological or physical (“psychosomatic”) symptoms.
Both depth-psychology-based psychotherapy and analytical psychotherapy (psychoanalysis) proceed from the premise that when a person develops depression, an anxiety disorder, crippling self-doubt or psychosomatic symptoms, it is no coincidence. Along with the patient, the depth psychologist and the psychoanalyst thus attempt to understand where the symptoms originate and to comprehend their “meaningfulness.” The therapist and patient generally discover which unconscious mechanisms underlie the present issue; what the “software” behind the symptoms look like; why and at what time this software was coded on the inner hard drive; and how it functions. This work of understanding and comprehension is similar to the labor of a detective or archeologist, who over time assembles a mosaic and thus “grasps” where problems and difficulties originate.
In this way, the patient renders conscious old software programs that have up to now either been internally slumbering unnoticed or that are continually automatically/unconsciously „booted up.“ The patient can then either delete them on the "inner hard drive" or replace them with more modern, up-to-date software. No longer in need of developing symptoms (e.g. anxiety, depression or physical) that restrict his or her life, the patient sheds them.
Sigmund Freud, whose explorations form the basis for both of these therapeutic methods, once put it this way: through "revelatory methods" (as both depth-psychology-based and analytic psychotherapy are also called), the patient can again become "master in his own house." This means that the patient no longer has to stand bewildered and helpless before his or her own distressing symptoms.
Emotional suffering surpasses every other illness in its constriction of the human capacity for experience and joy in life (anyone who has ever suffered from depression, anxiety attacks or crippling self-doubt can testify to this). It is in this context that Sigmund Freud coined the term "observation sets us free," which means: "going in depth" and understanding our own unconscious processes enables us to eliminate the distressing symptoms that are restricting our human potential. In encounters with world literature, film history or your environment, you will note that they are rife with psychoanalytic thought and mechanisms; and it is thus no coincidence that for decades, terms like "unconscious" or "repression" have become integrated in general language use.
Behavioral therapy (even if it might be somewhat simplified in the following presentation) is less interested in the unconscious reasons or biographical developments that underlie mental illness. The approach is more of a “practical” one: the attempt is to find solutions with the patient in the "here and now," solutions that are sometimes implemented with the direct assistance of the therapist. In behavioral therapy, the model of illness is based on the idea of learned behavioral patterns; particular emphasis is placed on the identification of factors that condition, intensify or prevent illness. Behavioral therapy treatment frequently establishes strategies and goals that are "concrete" and "on the drawing board," the implementation of which is regularly calibrated anew.
What are some criticisms of these therapeutic methods?
There is a classic joke told about the revelatory methods of psychotherapy (depth-psychology-based and psychoanalysis): two friends meet after a couple of years. One asks the other: "Hey, you started psychoanalysis years ago because you were soiling your pants. How is it going today?" The friend replies: "Well, I´m still soiling my pants, but now I know why." This joke contains a frequently articulated criticism, one however that does not apply in the vast majority of cases: that depth-psychology-based psychotherapy and psychoanalysis forget all about the symptom – the reason the patient came to therapy -- because they are too busy "psychologizing" and "pouncing on the bad childhood."
By contrast, the criticism of behavioral therapy is that it often focuses exclusively on "erasing" the symptom. It is like the paint treatment of a car: it looks good for a short time afterwards, but underneath the surface the rust continues to eat away and is sure to appear at the same or a different place. As applied to people, this means that very frequently, a patient with an anxiety disorder can rapidly shed his or her fears using behavioral therapy methods. Yet if this anxiety disorder is rooted, for example, in an unconscious burden of heavy guilt or fears surrounding the placement of trust in others and being able to speak one´s mind to them, then the unconscious psychodynamic (in the parlance of depth psychologists) will often find itself another outlet and appear as a different symptom at a later time.
I myself did not become a behavioral therapist, but rather trained in the methods of depth-psychology-based psychotherapy and analytical psychotherapy (psychoanalysis). These are very closely related to each other and share a theoretical foundation. I did so because my experience day in and day out is that human beings have an inborn need for explanations and meaningful structuring of their world ("Man´s Search for Meaning"; "I think, therefore I am"). The question, “Where do I come from and where am I going?” and with it the historicity of human beings: this, in my opinion, is of central importance.
Even as I fully recognize the successes of behavioral therapy and would without hesitation recommend it for a patient for whom I deemed it indicated and expedient: for me, the human spirit has too many aspects and a more dynamic complexity than the elimination of symptoms simply by relearning and retraining would imply. Since it claims for itself the privilege of shorter treatment duration and thus better benefit assessments, behavioral therapy is currently enjoying great popularity in our health care system. But the human spirit has its own laws, and psychological illnesses and change – as opposed to appendicitis, a urinary tract infection or a migraine attack -- frequently require more time than health insurance companies would wish.
With the increasing pressure on costs in the health care system, the responsible parties are increasingly interested in quick and successful (but frequently only short-term and superficial) treatments. This is a phenomenon that not only psychotherapy generally has to address, but in particular depth–psychological treatment and psychoanalysis. These phenomena are moreover also an expression of a general development in the industrialized world, in which supportive structures, individuality and interpersonal interaction have become increasingly less important. Human beings are now measured by way of their "performance" and "efficiency." I do not wish to present myself here as an unworldly romantic with regard to society, but in my long years of practicing psychotherapy I have treated a large number of executives and socially well-established people whose problems were rooted in precisely this phenomenon.
Which form of psychotherapy is the right one for which problem?
This question can usually only be answered individually following a diagnostic interview. What can be said is that behavioral therapy demonstrates its methodical strengths above all in the treatment of addictive disorders, severe compulsions and many anxiety disorders (for example generalized anxiety disorder or phobias). As of a certain degree of severity, eating disorders (such as anorexia or obesity) can frequently only be "taken hold of" by behavioral therapy approaches.
The domains of depth-psychology-based psychotherapy and psychoanalysis lie, first, in the area of "problems with others," i.e. problems in relationships with others. These can be present difficulties in work or private environments, like -- and above all -- continually recurring patterns in relationships to others (constant failures in relationships, frequent confrontations with others, repeated humiliations). Depression, self-esteem disorders and psychosomatic symptoms are a further domain of depth psychology/psychoanalysis. In addition, many anxiety and panic disorders, phobias (e.g. surrounding illness and infection), eating disorders or compulsions can frequently be successfully treated only with the dis-covering and processing approach of depth psychology/psychoanalysis.
As mentioned above, the indication for a certain method of therapy cannot be made sweepingly or purely by way of symptoms; a diagnostic interview is necessary. You can find more information on this under the section: "The Course of Individual Therapy."