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The Course of Individual Psychotherapy

Frequent Fears and Feelings at the Outset

On the one hand, the decision to go to a therapist evokes in many people apprehension (what awaits me there?); and, on the other, a feeling of having personally failed. Many people – particularly men – experience going to a therapist as a personal defeat, a "failure," and are ashamed of it. People with depression, in particular, are prone to blame themselves for their situation or are convinced that they have to "do it themselves."

Many people further imagine that "nutcases" or at a minimum very strange people visit psychotherapists, an impression to which countless jokes and cartoons have contributed. In contrast to this stands the experience frequently reported by patients: when they "out" themselves as having begun psychotherapy to family, friends or co-workers, they often hear the reply: "That´s good, I did it a couple of years ago and it helped me a lot." It helps to be reminded as well of the many celebrities who particularly in recent years have publicly admitted to mental illness and/or successful psychotherapy treatment.

Mental problems and illnesses are often indiscriminately equated with psychosis, which is how illnesses of schizophrenic origin are designated. These are illnesses in which the patient´s thought processes are severely compromised along the lines of a delusional experience or a delusional interpretation of the world ("I am Napoleon") or a feeling of being threatened or persecuted ("paranoia"). These illnesses must be handled by a psychiatrist (neurologist) and can be treated in the first instance only with medication and frequently only in a psychiatric clinic. Although there are many points of contact between psychotherapy and psychiatry, one is not likely to meet “crazies” in a psychotherapy practice and one need not fear being labeled as “crazy” – just as psychiatric clinics do not operate like “One Flew Over the Cuckoo’s Nest.”

The So-Called “Initial Interview“

Following the scheduling of an appointment, the so-called "initial interview" takes place. In the initial interview, the therapist at the start generally asks the patient to talk as freely and openly as possible about his or her problems and the reason s/he has come to therapy. The therapist will probably ask only few direct questions during the initial interview: it is more important for him or her to experience how the patient describes problems or in what order complaints are reported. At the end of this first conversation, the therapist should give the patient some feedback about whether s/he is "in the right place" and whether his or her symptoms really are treatable with psychotherapy; or whether other (medical) experts should be consulted to ensure a correct diagnosis.

The therapist may conclude that the patient cannot be treated by him or her personally. This could have to do with professional considerations (Is another form of therapy more suitable? Is hospitalization indicated?); or with personal partiality (common points of personal contact or involvement with the patient). In this case, the therapist should explain the situation to the patient and, if possible, provide another point of contact. For patients it is often painful when the therapist tells them that it might be better to get help somewhere else ("Then I have to tell my whole story again"). Psychotherapy is indeed a tough and stressful job for the patient, often lasting over a year. It is thus crucial to find the "optimal" therapist, so that after a year of work it does not have to be conceded with a shrug that a different therapeutic approach or a therapist with a different emphasis would have been better.

The So-Called "Trial Sessions" or "Probatory Sessions"

If following the initial interview it appears to the therapist that a course of psychotherapy would be useful and "promising," s/he will suggest that a further appointment be scheduled. Both statutory and private insurance guarantee the bureaucratically uncomplicated reimbursement of a total of five of these so-called "probatory sessions." During these sessions, the therapist will gather "diagnostic material." Just as a medical internist might take blood samples, prescribe an EKG, listen to the lungs or take an X-ray in order to render a diagnosis and select the proper treatment, the psychotherapist must also collect "results" and "diagnostic material." In the case of depth-based-psychotherapists and psychoanalysts, the therapists will ask among other things about the biography of the patient and attempt to reconstruct the kind of relationship formation; s/he will also observe the way in which the patient deals with feelings and ask about his or her own ideas about the reason for the problems at hand. Often the therapist will offer so-called "trial interpretations," i.e.: an idea or a model about the medical history of the patient.

The goal of the probatory sessions is for the therapist to gain clarity regarding the patient´s clinical picture and difficulties. In this way the therapist can become more certain that the psychotherapy work with this patient will in fact lead to the mitigation or disappearance of symptoms. The patient can in turn use the sessions for him- or herself. First, s/he should ask whether s/he gets something out of what the therapist has been saying about the therapeutic method and the course of therapy; whether it is a good fit with his or her personality; and whether – despite all the still open questions and uncertainty about where the "therapy journey" will go -- s/he has the feeling that the therapist can actually help. Secondly, the patient should consider whether the "chemistry" with the therapist is good. Several studies have shown that an authentic and primarily positive "chemistry" between patient and therapist (regardless of therapeutic method) is a determining factor in the success of psychotherapy.

Often, the patient and therapist will together decide together to apply to the health insurance company for a course of psychotherapy even before the end of the first five sessions.

Applying to Health Insurance or Aid Authority for a Course of Psychotherapy

For patients with statutory health insurance, the therapist can apply for short-term therapy: by relatively unbureaucratically filling out a form, s/he can request up to 25 sessions. Since however in the vast majority of cases psychotherapy lasts between 50 and 80 sessions (in some cases significantly longer), it is usually necessary to apply to the insurer for a course of long-term therapy. For this “Evaluation Procedure,” the therapist must complete a comprehensive, anonymous report of 4-5 pages. The insurer then passes on this highly confidential report to an external appraiser for review of whether psychotherapy is indicated, useful, and "promising."

Private patients – including foreign patients who are insured by foreign private insurers – will likewise normally be reimbursed for the costs of psychotherapy. The regulation of private insurers is however not standardized. Many private companies pay for a certain allocation of hours per year (around 20 or 30 sessions annually); others compensate the first 25 sessions without much bureaucracy or complication and only request a detailed report from the therapist after that point. Some private companies reimburse for psychotherapy sessions only after the review in the so-called "Evaluation Procedure" (see above). Private patients are advised to ask their insurance companies about exact procedures during the probatory period.

A Note About Privacy

Given the highly confidential nature of data in psychotherapy, privacy is an important topic. Many patients worry that anyone and everyone could gain access to their data. It has been my experience over many years that there is no reason for concern: particularly confidential reports are anonymous and encrypted. No health insurance employees have access to the content of such reports, the envelopes of which are sealed and marked accordingly.

Agreements between Therapist and Patient

Over a projected course of psychotherapy, therapist and patient will have some housekeeping matters to arrange. As a rule, the search for a regular, fixed weekly appointment is attempted (unless for example the professional circumstances of the patient do not allow for such regularity). The therapist will ask and encourage the patient to narrate everything that is going through his or her head at that moment, even if it appears unimportant, ridiculous, embarrassing or irrelevant. The therapist will also make the patient aware of the regulation of cancellation fees, which is customary worldwide: the patient will be charged for a session that is not cancelled within a certain time period (normally 48 hours or less) unless the therapist can fill the hour in another way.