Germany’s mental health system in a nutshell Shedding light on the confusing German therapy system
Summary: German health insurance sometimes pays for a course of mental health treatment. However, this only applies to certain problems and only a few therapy types can be used. Even when the situation fits these criteria, over demand for health care providers can result in long waiting lists, and the client can face being given a mental health diagnosis that could affect future insurance opportunities (e.g. disability insurance). For those willing to pay for mental health care, Germany provides a selection of trained professionals that can offer a variety of methods to suit the client. Waiting times are far shorter, any treatments or diagnoses remain completely anonymous, and the costs can be, in many cases, reclaimed from tax payments. In order to ensure you chose a suitably qualified therapist, look carefully at their qualifications and expect to pay between 60 and 100 euros.
By Jan Kaspers, 03.05.2016
To exaggerate it: for most foreigners the German health insurance system must look like a complicated, expensive and bureaucratic mess. Indeed it is not that easy to understand, especially if you should come from a health system that is still centralized or has no mandatory insurance policy. In this article, I try to briefly explain the German health system, with a focus on mental health providers and practitioners. I try to shed light on its confusing structures and insurance conditions. Finally I try to argue the conclusion that self-payment can be a viable option for people who are currently suffering from mental strains and are in need of psychological treatment.
Mandatory insurance status
In contrast to other countries, having health insurance is mandatory in Germany since 2009. Before that time, there were still possible exceptions to the rule. Since 2009, each private person in Germany must possess health insurance. There are basically two options: the public and the private health insurance. Public health insurance is open to everybody, no matter if employed, self-employed or unemployed. Private health insurance is accessible only to students, self-employed people or employed people above a certain income. Most people (around 85%) are insured by the public health insurance. Accordingly, I will mostly focus on that type of insurance in this article.
If you should be employed, then the costs for the public health insurance are split between you and your employer. The amount is a percentage of your before-tax income. If you are unemployed, the state system usually pays for your insurance. If you are not employed and don’t have the right to claim unemployment benefits (as might be for freshly arrived foreigners), then you have to pay a fixed rate on your own behalf, which is usually between 150 and 200 euros a month and can be a real financial burden.
The public insurance system is best described as a public system with semi-privatised insurance providers. The insurance providers were originally classified into professional sectors. Until 1996, one couldn’t choose the public health provider – the assignment was basically determined by your profession. Since then, there is a free choice of your public health insurance provider, and in consequence a competition between those providers developed. For this reason, it makes sense to check the internet for the best providers in your region, as they all differ in insurance rates and variety of health benefits.
The health insurance system is a supporting pillar of the social state and a guarantee for an overall healthy population. The public health system works by the principle of solidarity, which means that one is not paying for the health of oneself only, but for the health of the whole population. Children and old people who can’t provide any contributions to the system are thus protected as well.
Any form of standard treatment is paid for by the system to a certain amount. Particularly in the mental health sector, there are special rules for cost absorption. In the case of a diagnosable mental disorder, any insured person can claim their first psychotherapeutic treatment in one of the approved methods from the social system (see below). The treatment is financed usually up to a maximum of two years. A standard treatment is one year. Short-term therapy is considered 25 sessions. After the maximum therapy time, the patient normally gets blocked for therapeutic treatment for two years, until he/she can claim another therapy. To obtain therapy, the patients themselves seek a suitable psychotherapist that works for the public sector with an approved licence (“Kassenzulassung”). In theory, any insured person should be able to get a treatment within a month. Unfortunately, the demand is very high and there is no attempt by the government to provide more treatment providers, which leads in practice to a long waiting time. In the following, I will speak about the sometimes confusing forms of mental health practitioners in Germany.
The actors on the stage
As in every country, there is a range of people working in the field of mental health. In the following I will describe the most common and important ones for the German mental health care system. I will explain the differences, and discuss when it makes sense to contact a certain practitioner. Please notice that the people working in psychiatric and psychosomatic clinics can vary from the people mentioned below.
“Facharzt für Psychiatrie”
(M.D. in psychiatry)
Like in almost every other country, a psychiatrist is a medical doctor (M.D.) who specialized during his studies in the treatment of people with mental health problems. Psychiatrists see the field of mental health mainly from a physical perspective, and treat their patients usually with a range of appropriate psychopharmaceutical medication. Psychiatrists are usually the right contact for people who suffer from severe mental disorders like schizophrenia, severe depressive episodes, bipolar disorders, and other problems that can’t be helped by purely talk-based psychotherapy. The patient usually goes more frequently to a consultation in the beginning of the treatment, and then after a while, attends only each quarter of a year for monitoring reasons until he has reached a stable medication and better functioning. Often psychotherapists and psychiatrists work together, one for frequent talk psychotherapy, the other for medical treatment. The costs for consultation of a psychiatrist are always borne by the public German health insurance.
“Facharzt für Psychosomatische Medizin und Psychotherapie”
(M.D. in psychosomatic medicine and psychotherapy)
Like a psychiatrist, this person is also a medical doctor, but with a different form of specialization. This form of doctor treats people with medication as well as with talk psychotherapy. Unlike a psychologist, this practitioner has focussed on the studies of the human body. In a second step, he then became a professional for mental health. As medicine usually sees mental problems as “coming from the inside of the person”, those practitioners are traditionally specialized in psychodynamic and psychoanalytic methods of treatment. The costs for consultation of this kind of doctor are always borne by the public German health insurance, whether it’s for medication and/or talk psychotherapy reasons. The waiting lists for talk psychotherapy can be quite long though (see below).
Psychologists have studied the human psyche in all its variations. Psychology is nowadays mostly seen as an empirical science with a broad range of methods. Psychology uses a lot of statistics and has become its own science, with many connections to its relative neighbours in medicine, biology, philosophy, sociology and computer sciences. In Germany, many psychologists learned in the early stages of their studies about different fields of psychology, e.g. social psychology, biological psychology, neuroscience, personality studies, etc. Later on, they specialize in certain areas. Those people working in the mental health sector usually specialize in clinical psychology, often with a second focus like neuropsychology or diagnostics. Clinical psychology in Germany is widely dominated by cognitive-behavioural therapy. Most psychologists accordingly learned a lot about this therapeutic method before they did any further training. Being a psychologist is an academic degree. In the old educational system the German diploma was standard. A decade ago, the Bachelor- and Master system was widely introduced in Germany as well. The title itself does not necessarily lead into the admission of a job as a counsellor.
Those are the psychotherapists that can bill via the German public health insurance. They are all clinical psychologists on a Masters level (or an old diploma) who undertook a highly structured training after their studies that usually took three to five years. Unlike many other countries in the world, the German law situation only allows the public health sector to pay for three different therapy methods. Those methods are cognitive-behavioural-therapy, psychodynamic therapy and psychoanalysis. For any other form of therapy, the public health sector won’t pay, even if many other methods reached a reputation of scientific approval. That means that psychological psychotherapists also have to stick to those methods in their training if they plan to bill later via public health providers. Also, they can only bill via public health insurance if they possess the so called “Kassensitz”, which is a licence from the health system. Those licences are very rare, very expensive (50.000 – 100.000 EUR) and also strictly limited to a certain number, linked to the number of medical doctors in a region. This number turns out to be not sufficient. As there are on the one hand an increasing number of people who would like to receive psychotherapeutic help, and on the other hand there are a limited number of licences, the waiting lists for people attending psychotherapy exploded in the last ten years. Particularly in metropolitan areas, the demand is very high. At the moment, the usual waiting times for psychotherapy in Berlin can be between one and six months, a time in which help can sometimes be even too late. As a reaction, psychological psychotherapists increasingly used a leak in the mental health system to bill without having the above mentioned permission. The system owns a rule, that if there have been certain attempts to get a therapist within a certain time an inquiry (“Kostenerstattungsverfahren”) can be send to the public health insurance provider, that forces the health insurance to meet the costs for a therapy. The insurance provider can decline the inquiry in the first place though, which is usually followed by a revision of the therapy seeking patient. After this leak in the system became increasingly popular, those numbers of therapy attempts also started to explode. Whereas in the year 2004 around two million euros were spent using this inquiry-method to attain paid psychotherapy, in the year 2013, 15 million euros were disbursed. As a reaction, some public health insurance providers started to stop the payment over this method, which then in return led to an increased number of lawsuits. All in all, there is no solution for the problem of high demand yet.
“Heilpraktiker für Psychotherapie”
(Non-medical practitioner for psychotherapy)
The regulation for this sort of practitioner is very old and goes back to the middle of the 20th century. Beside the allowance to work as a medical doctor and as a psychological psychotherapist, the allowance as a non-medical practitioner for psychotherapy is the only remaining option to legally work in the field of counselling. The requirements to become a non-medial practitioner are not as highly regulated as being a doctor or psychological psychotherapist. After passing a one to two year long course, people are awarded this title after a successful final exam and a clean police record. The costs for psychotherapy by a non-medical practitioner are usually not borne by the public health insurance. Yet some public providers offer additional packages that reimburse the costs for psychotherapy with non-medical practitioners to a certain amount. The same is true for some private health insurance companies. However, the majority of practitioners in this field bill via private payment only. Going to a non-medical practitioner and paying for your therapy can have benefits for the whole process. The biggest advantage of all is that people who pay for their treatment usually carry a bigger motivation for change, which lowers the overall costs due to shorter therapy times. Since it is not linked with the insurance system, private therapy can take place in anonymity and without facing painful bureaucracy. Furthermore, clients can choose from a wide selection of psychotherapeutic methods that are otherwise strictly limited by the public system (see above). Additionally, the costs for therapy can be deducted from the tax, and usually non-medical practitioners can offer a prompt start to therapy.
As the permission for psychotherapy by non-medical practitioner allowance is easier to get than the other titles, it is very important to look at the further qualifications of the counsellor. A person who worked before as a car seller or banker might not bring the same qualifications as someone who worked in the social field, e.g. a qualified social worker or psychologist. A psychologist for instance holding a Masters degree in clinical psychology gets the allowance as non-medical practitioner without any further exam, as the studies he/she undertook are more advanced than the content of the usual exam curriculum. Also, further qualifications like an additional therapeutic training, including self-awareness seminars and professional supervision, are a minimum requirement for a quality non-medical practitioner, as well as years of education and working experience in the social field. Furthermore, non-medical practitioners usually work only with less severe mental problems. One further important benefit is that you don’t necessarily need to get diagnosed as “mentally ill” (an official diagnosis which will be retained on your health records), which can be also helpful for getting certain types of private insurance in the future. For all other forms of severe mental problems, consulting a psychiatrist or general practitioner is recommended.
“Coaches” and “Paartherapeuten”
(Coaches and couples counsellors)
Coaching and couples counselling are not protected terms by the German law. Therefore anybody can call themselves a professional in that business. If you should consult a coach or couples counsellor, check their qualifications carefully. Ideally, a coach or couples counsellor has one of the above mentioned titles, whether it is a medical doctor, a psychologist, a psychotherapist or a non-medical practitioner with relevant qualifications. Also, some associations now offer exams and trainings in coaching. Crucially, for coaching and couples counselling, no public or private health insurance will bear the costs, as that system only pays for diagnosed disorders of individuals.
A guide to reasonable self-payment
As you can see in the above mentioned circumstances, to get quick help for mental health problems, self-payment can be a reasonable option, especially in contrast to long waiting times and bureaucratic control. Many foreigners are used to paying for mental health treatment on their own anyway. That is normal in many public health systems all over the world. Germans might in fact be “spoilt” with the insurance payments, and might therefore not value quality therapy as much as foreigners. The only point that often remains unclear is why one should pay for therapy, when the public health insurance is already very expensive. Indeed Germany has a very expensive system – a usual employee pays 7-8% of their before-tax income to health insurance providers. Self employed people even pay double that amount. Taxes and other social services such as unemployment, disability and retirement insurance come on top. Currently, is doesn’t look like as if there are any major reforms coming up, it even looks as if the situation in the health sector is getting more difficult when it comes to funding. Therefore it might be important to act on your own and not wait for the system to change if you should be really in need of help and self-growth. Sometimes it can be even more important to invest money into seeing a professional rather than waiting too long, as chronic manifestation of mental problems can be even more expensive at the end, e.g. leading to long periods of work incapacities. With those facts in mind, one might pose the question of what a reasonable price for professional mental health treatment might be. The quick answer is: anything that the public health insurance would pay. The billing catalogue of the public health insurance charges for an hour of psychotherapy roughly 85,- EUR currently. Therefore reasonable prices for therapy usually fluctuate around that amount, often between 60,- and 100,- EUR per session, depending upon experience of the therapist, client availability situation, social ideals, living area, prestige and many other factors. If that should sound a lot for you, it might make sense to keep in mind the other costs that add up for the therapist and have to be subtracted from the hourly rate: taxes, rent for the practice rooms, office materials, energy costs, constant professional training, special insurance, costs for the web presence, etc. Additionally, therapists have to prepare for their clients next appointment, they are occupied with answering their clients’ calls and emails, are organizing their own schedule and making appointments. Therefore you can easily add another half an hour to hour working time for any actual hour of counselling. If you should find therapists who work below or above that range I provide here, you should double check their motivations. A price lower than 60,- EUR per hour is most of the time economically not profitable anymore. A therapist who charges that amount consequently is likely not able to live from that money. Conversely, rates over 100,-EUR per hour cannot be appropriately related anymore to the clients’ outcome, except in the case that the counsellor is a specialist in an certain uncommon field. Usually you can expect that a counsellor comes from a social background and has no need to exploit their clients and also wants to feel “okay“ about the prices he charges. Also – even if it might be strange in the beginning to think that way – there is a market for psychotherapy as there is a market for any other service in the world. Under- and overpricing can be destructive for the market and its participants. You basically pay a therapist for their time, professional understanding and skills. The job is emotionally and mentally challenging, which means most therapists don’t take more then 10-20 parallel clients. Even if the job itself can be very rewarding on a personal level, the therapist has to live from it. You can see the pricing that is in the above mentioned range is a minimum requirement for high-quality counselling.