The Role of Psychotherapy in the German Health Care System: Training Requirements for Psychological Psychotherapists and Child and Adolescent Psychotherapists, Legal Aspects, and Health Care Implementation

In Germany every citizen must acquire either public or private health insurance from companies which then cover the expenses for psychotherapeutic in-patient and out-patient treatments within a given set of regulations. Since the commencement of the Psychotherapists' Law in 1999, psychological psychotherapists and child and adolescent psychotherapists are permitted to diagnose and treat mental disorders with psychotherapy under their own responsibility as a legally defined healing profession. Psychotherapists have to use scientifically approved psychotherapeutic approaches for treatment. The qualification and licensure of psychotherapists are highly regulated by the Psychotherapists' Law, which is currently undergoing a process of change.

In Germany with its 83 million inhabitants expenditures on health in 2015 totalled 343.5 billion euros, equalling 11.3% of the gross domestic product (Gesundheitsberichterstattung des Bundes, 2017). The costs caused directly by mental and behavioural disorders amounted to 44.3 billion euros (Statistisches Bundesamt, 2015). Mental health care is becoming increasingly more important.
Health insurance is provided through either public or private health insurance. Public health insurance is open to everybody, regardless of whether they are employed, self-employed, or unemployed. German citizens who are mentally or physically ill are entitled to all available treatments necessary for healing.

Mental Health Care
Mental health care in Germany is mainly provided by office-based psychotherapists, psychiatrists and eligible medical doctors, psychiatric hospitals, psychosomatic clinics and psychiatric outpatient clinics. In addition rehabilitation centres, community mental health care centres, and different types of residential facilities provide a broad spectrum of nonmedical vocational, residential, and psychosocial counselling services (Salize, Rössler, & Becker, 2007). Sundmacher et al. (2018) calculated that 1.9 million patients per year are treated in outpatient psychotherapeutic care. Gallas, Kächele, Kraft, Kordy, and Puschner (2008) found a median therapy duration of 16 months, ranging from 13 months (cognitive behavioral therapy) to 24 months (psychoanalytic psychotherapy). Approximately a further 960,000 patients per year are treated in psychiatric and psychosomatic inpatient care. The average treatment duration for mental disorders in hospitals in 2017 was 24.2 days in total, 27.4 days for female and 21.2 days for male patients, respectively (Augurzky, Hentschker, Pilny, & Wübker, 2018), with huge differences between psychiatric (23.8 days) and psychosomatic (42.9 days) inpatient care (Statistisches Bundesamt, 2017).
Access to mental health care is basically free of (extra) charges for most people in Germany which is an uncommon feature among member states of the European Union (Strauß, 2009).

Regulations for Psychotherapists
Unlike some other European countries Clinical Psychology is not an independent profession in Germany. In 1999 the legal basis was laid for psychologists to ultimately practice independently and on their own authority. In Germany the profession of psychotherapist has been regulated by law since 1999 (Gesetz über die Berufe des Psychologischen Psychotherapeuten und des Kinder-und Jugendlichenpsychotherapeuten, PsychThG, 1999). The Psychotherapists' Law (German: Psychotherapeutengesetz, PsychThG) regulates the practice of psychotherapy as well as the qualification and licensing procedure of nonmedical professions, e.g., psychologists. In this article, we specifically focus on the legal requirements for training and licensing psychological psychotherapists and child and adolescent psychotherapists. For medical doctors there are different regulations.
The law (PsychThG, 1999) legally created two new professions, namely psychological psychotherapists and child and adolescent psychotherapists (who are allowed to treat only children and adolescents under the age of 21). In 2018 this law was undergoing a major change and will be set into place by the end of 2019. According to the new law in future there will be only one profession called psychotherapist.
The old and the new law define psychotherapy as a practice using scientifically approved psychotherapeutic approaches for the assessment, cure, or alleviation of mental disorders. This has implications for postgraduate training because the Scientific Advisory Council for Psychotherapy, which is formed in equal parts by scientific representatives of psychotherapists and specialised medical doctors, has currently only approved psychoanalysis, psychodynamic psychotherapy, cognitive behavioural therapy, and family therapy for the treatment of mental disorders. For the treatment of injuries or illnesses of the brain neuropsychological therapy is approved. Consequently, students are restricted to becoming licensed in the aforementioned approaches.

Qualification and Licensure -The Current Status
According to the "old law" currrently the qualification of psychological psychotherapists and child and adolescent psychotherapists is regulated separately for each profession (Ausbildungs-und Prüfungsverordnung für Kinder-und Jugendlichenpsychotherapeuten, KJPsychTh-APrV, 1998;Ausbildungs-und Prüfungsverordnung für Psychologische Psychotherapeuten, PsychTh-APrV, 1998). Academic social workers and educators who have obtained a master's degree complete an equivalent postgraduate training in child and adolescent psychotherapy, but the educational framework is identical to that of psychological therapists.
Overall, the qualification process has to have a minimum duration of three (full-time) or five (part-time) years of postgraduate specialist practical training in psychotherapy and certification in an approved psychotherapeutic approach. This long-term, postgraduate training for psychotherapists is unique within the European Union (Strauß & Kohl, 2009). In order to register for the state examination, psychotherapists in training need to complete four modules comprising theoretical education, practical internships, practical supervised training, and self-experience (see Table 1). In particular, students have to complete 600 hours of continuing coursework, 1,800 hours of clinical experience in an inpatient setting (a minimum of 1,200 hours in a psychiatric hospital and 600 hours in a rehabilitation hospital or in a licensed outpatient setting), 600 supervised outpatient treatment sessions of at least 6 patients (including 150 hours of accompanying supervision), and an additional 930 hours of unspecified psychotherapy-related coursework. Furthermore, self-experience plays an important role in the training of psychotherapists, as future psychotherapists are required to complete 120 hours of one-to-one or group sessions or a mixture of both settings. In practice the described demands in training can be significantly higher, i.e. for the psychoanalytic approach.
After these requirements are met, psychotherapists in training then need to pass a state examination comprising a written and an oral exam. After passing the state examination, candidates are licensed. This structured postgraduate training in psychotherapy is organised by universities and state-licensed institutes. In total, 254 postgraduate training programs were offered by 215 state-licensed educational institutes and 39 universities (unith e.V., 2018). Nearly 2,700 students took part in the written state exams in 2016, 1,900 for a license in psychological psychotherapy and around 800 for child and adolescent psychotherapy. This shows an increase of 17% of graduates compared to 2015 and an increase of 61% compared to the previous five-year period.

Qualification and Licensure in the Future
The German Psychotherapists' Law had to undergo long-overdue adjustments and an educational reform for several reasons. The first reason is that the current graduation system is not adjusted to the structure of bachelor and master degrees which was not implemented in Germany in higher education until 2013. The federal state government agencies need more precise legal specifications to be able to fulfil their statutory responsibilities (i.e. standardised admission requirements to the postgraduate training) and thus ensure a high-quality standard of postgraduate psychotherapy training nation-wide. Another area that needs significant improvement is the very low level of payment during postgraduation training. At the moment their legal employment status is not properly regulated (Wissenschaftsrat, 2018). Additionally psychotherapists in training have substantial financial expenditures. Students have to pay between 20,000 and 30,000 euros on average in tuition fees . Furthermore, the development of psychotherapeutic knowledge is developing very rapidly and subsequently adaptations of the training acquirements are necessary.

Modernisation of Current Psychotherapy Training
In 2014, the German psychotherapists' meeting (German: Deutscher Psychotherapeutentag, DPT) passed a resolution, after a two-thirds vote, to campaign for a reform of the current psychotherapeutic training and a modernisation of the underlying Psychotherapists' Law (Bundespsychotherapeutenkammer, 2014). The core idea is to adapt the structure of the (postgraduate) training program for psychotherapists to the structure of education of medical doctors. A central part of this proposal is the implementation of a consecutive bachelor's and master's (of science) degree in psychotherapy studies as a requirement for the admission to the postgraduate advanced training program. It is suggested that during this advanced training phase, psychotherapy trainees specialise in either the treatment of adults or of children and adolescents in an approved psychotherapy approach, e.g. psychodynamic, behavioural or systemic psychotherapy (Bundespsychotherapeutenkammer, 2014).
During the discussion of the role of future psychotherapists in the German health care system, the question arose of whether and to what extent traditional competences of psychotherapists should be expanded (e.g. regarding certificates for sick leave from work).
In contrast to the current system, there is a given set of regulations for the mandatory contents of basic scientific and practical psychotherapeutic knowledge in the bachelor and master courses. In addition to the master's exam, a state-controlled exam is mandatory for receiving the formal psychotherapy licence (in German: "Approbation"). This licence is the prerequisite for entering the subsequent advanced psychotherapy training. In the advanced training program psychotherapists will be employed in specialised hospitals or outpatient clinics (legally, the advanced training program will be officially regulated by the state chambers). Currently, the Federal Chamber of Psychotherapists considers a duration of 5 years (full-time employment) as necessary for the advanced training (with a minimum of 2 years in an outpatient setting and 2 years in a hospital setting). The advanced training will contain the training in an approved psychotherapy approach and either in the treatment of adults or in the treatment of children and adolescents. The official licence of treatment for psychotherapists in an own practice (that allows for remuneration by the insurance companies) will require a successful completion of advanced training.
The new law was passed by the German parliament (Bundestag) in September 2019 and approved of the parliament of the governments in the federal states (Bundesrat) in November 2019. The new educational system for psychotherapists is due to start in October 2020.

Professional Organisation
In Germany, state law requires psychotherapists (psychological psychotherapists, child and adolescent psychotherapists -and all future psychotherapists) to be compulsory members of a state psychotherapist chamber (Heilberufe-Kammergesetz, 2002). Its principal responsibility is the supervision of occupational standards. The state chambers, which are organised on a national level in the Federal Chamber of Psychotherapists (Bundespsychotherapeutenkammer, BPtK), therefore work as public corporations. The BPtK represents some 50,000 psychotherapists in Germany and is thus the only professional organisation to represent all psychological psychotherapists and child and adolescent psychotherapists in Germany. In 2015, two thirds of its members were working in an outpatient setting and their mean age was 52 years; one third are even 60 years or older. Seventy two percent of its members were female. This ratio is likely to shift even more in favour of female members in the next decade. Among the age group of 35 year-olds and younger, the percentage of female psychotherapists is already close to 91% (Bundespsychotherapeutenkammer, 2016).

Outpatient Psychotherapy
The Federal Joint Committee (German: Gemeinsamer Bundesausschuss, G-BA) is the highest decision-making body of the joint self-government of physicians and psychotherapists, dentists, hospitals, and health insurance funds in Germany. It specifies which services in medical care are reimbursed for more than 70 million people within the statutory health system and also specifies measures for quality assurance in outpatient areas of the health care system. The Guidelines for Psychotherapy are published by the G-BA to ensure that all patients in outpatient psychotherapy are cared for in a qualified and adequate way (Psychotherapie-Richtlinie, 2017). Nevertheless, psychotherapy is limited to specific diagnoses according to the International Classification of Diseases Chapter 5 (F) German Modification (ICD-10 GM, Dilling, Mombour, & Schmidt, 1991). Indications are adjustment-, affective-, anxiety-, compulsive-, conversion-, dissociative-, eating-, sexual-, sleep-, somatoform-, personality-, and psychotic disorders as well as behavioural and emotional disorders in children. Psychotherapy can also be approved if psychological factors are pathogenetic or impair somatic health. Patients can choose their therapist freely from a pool of licensed psychotherapists. After consultation and possible probationary sessions, a subsequent application for psychotherapy is evaluated by an experienced psychotherapist based on a psychological report which includes anamnesis and biography, diagnosis, treatment planning, and prognosis. Approval of psychotherapy is thus based on professional opinion rather than health insurance company personnel. For outpatient treatment of mental disorders, the statutory health system covers only psychoanalysis, psychodynamic psychotherapy, and cognitive behavioural therapy. The costs of neuropsychological therapy are also covered for the treatment of injuries or illnesses of the brain. Limitations are set in terms of session quotas for each psychotherapeutic approach (e.g., for psychotherapy with adults in cognitive behavioural therapy: up to 80 individual sessions; psychodynamic therapy: up to 100 sessions; psychoanalysis: up to 300 individual sessions). As of 2018, systemic therapy has been approved by the G-BA and is in the process of becoming a psychological treatment which is eligible for reimbursement of treatment costs for adult patients (Gemeinsamer Bundesausschuss, 2018). Even though many more methods and techniques of psychological treatment have become familiar in the field of psychotherapy research today, the G-BA's approval policy remains rather conservative. Private insurance companies differ from each other in their medical service tariffs, but they are oriented towards the G-BA's Guideline for Psychotherapy.
In contrast, there are less stringent regulations for psychological interventions in psychiatric and psychosomatic hospitals and rehabilitation centres because inpatient treatment expenses are assigned to another cost unit of health insurance funds. Furthermore, in hospitals and rehabilitation centres the treatment responsibility is held by executive medical doctors. Their ability to freely chose and adequately provide treatment is guaranteed by a less narrow, i.e., less specific legal definition of medical practice in comparison to psychotherapists.

Desirable Changes to Mental Health Care Regulations
Changes need to be made in the areas of provision, planning for future demand and the educational training system for psychotherapists. Health economic analyses of the German mental health care system have shown that most of the financial resources are spent for inpatient treatment and outpatient drug prescriptions, while with approximately 2 billion euros only a small fraction of the budget is spent for outpatient psychotherapy (Jacobi et al., 2014;Kilian & Salize, 2010). The planning for demand of psychotherapeutic outpatient practices through regulations by the G-BA is outdated. There are up to three times more psychotherapists licensed per 100,000 inhabitants in urban areas than in rural areas (Bundespsychotherapeutenkammer, 2018). Consequently, the average waiting period for outpatient psychotherapy in the social insurance health system is around four months in metropolitan areas and five to six months in rural areas (Bundespsychotherapeutenkammer, 2018). Recently the G-BA decided to change these regulations to improve the situation. Consequently, in the short term, there will be some improvement via additional psychotherapists but in the long term this new system implies a further deterioration of outpatient care of menatlly ill persons.
This discrepancy and an increasing economic burden of mental illness point to the need for further improvement (Jacobi et al., 2014;Murray & Lopez, 1996;Whiteford et al., 2013). It is expected that the effectiveness and efficiency of the German mental health care system can be significantly improved by an even further shift of resources from inpatient to outpatient care (Karow et al., 2012). A reform of the regulation system for the admission of statutory health care providers should therefore lead to quotas based on morbidity instead of location.

Consequences of the German Regulations for Research in Psychotherapy
The establishment of outpatient services within postgraduate training programs makes it easier to include patients in research projects. Most of the psychology departments in German universitites run a post-graduate program and thus have more possibilities to combine the outpatient service with research studies. But there are also some important limitations. As mentioned above the G-BA approved psychotherapeutic approaches are the basis for financing psychotherapy within the health care system. The admission to the health care system is also orientated on these traditional lines. Clinical psychology units provide professional experience and training-programs mainly for cognitive behavioural therapy and therefore there is a huge lack in possibilities for research for the other psychotherapeutic approaches. In the process of the reform the chambers and other professional organisations demand, that there should be more personnel at the universities with specific qualifications for teaching these other psychotherapeutic approaches.

Conclusion
Since the Psychotherapists' Law came into effect in 1999, the professional title "psychotherapist" has been protected by law and the training for becoming a psychotherapist is regulated on a high professional level. Every German citizen can rely on this high quality of training and subsequently expect professional treatment. Nationwide data show that more and more people with mental disorders are seeking help from psychotherapists. In consequence, the waiting period for professional treatment has become longer over the years. Despite increasing numbers of psychotherapists, even more psychotherapists for outpatient treatment are needed, particularly in rural areas. This situation is very similar in hospitals and specialized clinics for mental disorders. Consequently, evidence-based treatments following international guidelines cannot be offered to every patient due to a lack of qualified psychotherapists (both in outpatient and inpatient settings). The renewed law is expected to improve the training conditions for future psychotherapists and also meet the necessities of the health care system. Therefore, in the coming years the psychotherapeutic profession will appeal more to young students and will play an even more important role in the German health care system.