On the Future of a Profession
JUNKTIM Reaction to the Amendment to the German Law on the further development of health care (GVWG)
JUNKTIM Reaction to the Amendment to the German Law on the further development of health care (GVWG)
An intensive debate on the future of psychotherapeutic care is underway, which is visible under #RasterPsychotherapie and #keinerasterpsychotherapie and around 200,000 votes in the petition against the same. On 2.6.21, the relevant legal amendment was deleted – and JUNKTIM e.V. would like to contribute something to the future shaping of this debate with the help of linking practice and research.
The first occasion was Amendment No. 49 or 44 (according to the new print version) to the GVWG (“Gesundheitsversorgungsweiterentwicklungsgesetz”). It establishes innovations for therapeutic practice, laid down in the Fifth Social Code (SGB V). This amendment includes the following agitator:
In the many journalistic reactions (see box “Media” below), reference is made to this amendment of § 92 paragraph 6a SGB V and it is understood in such a way that (guideline) psychotherapy must in future be oriented in length and implementation to the diagnosis made at the beginning. However, these proposed amendments do not improve the treatment and management of mental disorders, according to the unanimous opinion, but rather this diagnosis-oriented “grid” consolidates – as in the search for criminals – the idea that therapists treat the wrong patients with ineffective methods and for too long (see Benecke 2021). Whether the therapists are the criminals in this Twitter metaphor or the patients is left to the eye of the beholder. Also, whether and to what extent it is helpful to maintain this metaphor of being persecuted. Metaphors are definitely helpful to collectively focus our thought and perception processes. Before we can turn to an alternative metaphor, let us look at the problem to be solved.
First of all, the legislator has the mandate to ensure health care and there are doubts in the area of psychotherapeutic care that this is ensured in every case, which became clear, for example, in a 2018 study by the Federal Chamber of Psychotherapists (BPtK): “Around 20 weeks [5 months, note JUNKTIM] waiting time for psychotherapeutic treatment” (see BPtK Waiting Time Study 2018). In the meantime (12.02.2021), according to the German Psychotherapists’ Association, 38% have to wait longer than 6 months for treatment to begin (see DPtV communication). Current studies, e.g. the COPSY study by the UKE Hamburg, point to an increased need for psychotherapy due to the Covid 19 pandemic (see results of COPSY) and also existing illnesses are becoming more entrenched with considerable effects on the overall social health situation (see study on the impact of Covid.19).
So the problem in therapeutic care is that too long waiting times for patients delay the timely treatment of diseases. But isn’t the solution then quite simple? If Benecke is right, and real patients are treated with effective methods of appropriate duration, then perhaps there are simply too few therapists to meet the demand? In 2020, there were about 2,400 therapists across Germany who successfully passed the written part of the examination for psychological psychotherapists (see IMPP archive), i.e. who were newly available as therapists to the statutory health insurance system, and according to the BPtK waiting times study, at least as many 2,400 more practice seats for psychotherapists would be necessary to drastically reduce the current waiting times (even 7,000 for the urgent adaptation of the country to the urban supply). So there are enough therapists.
But it is not only patients who are waiting, but also (especially newly qualified) therapists who are waiting a long, very long time for a panel seat (up to 10 years in Berlin), which they (in contrast to many of their predecessor generations) have to pay dearly (up to 100,00€ in Cologne). This is also reflected in the figures: in Germany there are “about 47,000 licensed psychotherapists – but only about 25,000 of them have a panel practice, 40 percent of them even only half a panel practice” (p. Psychologie Heute).
There is an urgent need for updated demand planning for psychotherapeutic care structures of SHI physicians, because the current SHI places are based on the values that were set in 1999 – but “the basis for the calculation of demand was not the actual need for treatment, but cost neutrality” (see Wochenblatt).
In a 2019 question to the Bundestag, the following complaint is made with reference to the BPtK waiting time study: “In the opinion of the questioners, therapy places for treatment under the guidelines are still not available to a sufficient extent” (see printed matter 19/19748). The answer of the Federal Government: The “demand planning to ensure the provision of care by SHI-accredited physicians [is] the sole responsibility of the G-BA”, i.e. the Federal Joint Committee, however, the first version of the “Guideline on the coordinated and structured care of seriously mentally ill insured persons across professional groups” will be available in summer 2021 at the earliest (see G-BA self-disclosure).
The search for the problem that is being attempted to be solved traces a process of previous attempts to solve it:
The fact that these attempts at a shortened, abbreviated and standardised treatment do not solve the problems of the actors is clear only insofar as therapists and patients who want to enter the therapeutic system (in order to get a place at a health insurance fund or to start therapy) have to cope with long waiting times. The attempts at solutions do not solve the existing problems of the actors, but are an expression of a view of psychotherapy as a stand-alone technique that functions independently of the actors. From this therapy-as-technique perspective, it makes sense to orient oneself towards manualised RCT studies with hand-picked, non-comorbid patients in extreme short-term therapies (cf. Benecke 2021), which, however, do not reflect the actual patients or therapists and thus only provide questionable transfer possibilities of the results. The extent to which actors of all psychotherapy methods then suffer from the implementation of the results in the form of guidelines has been convincingly presented by Cord Benecke (ibid.).
The basic technical understanding of psychotherapy is well known, you are all familiar with vocabulary such as “disorder” which is “eliminated” by “intervention” or “interpretation” and has been “diagnosed” beforehand. Psychotherapy research has emphatically warned against this treatment-as-technique or technical thinking in the psychotherapeutic profession since 2003. It is destroying psychotherapy, wrote Bruce Wampold. Michael B. Buchholz has been emphatically pointing out this danger since 2017. Therapists are then dealing with “sick” or “disturbed” people who need to be “cured” or treated. What is inherent in these vocabularies is above all a revival of the devastating stigmatisation and further a cognitive dimension of moral self-appraisals and devaluations of others, which unquestioningly unfold their effects in the therapeutic conversation, accompanied by a fading out of the interactive moment of therapeutic conversation.
As long as this metaphor of technical psychotherapy dominates, it is likely that there will always be supposed solutions that become (new) problems for the actors.
We would now like to invite you to take a little diversions with us. Let us look into a short sequence (Heritage, 1984) with the question: How can we understand this utterance?
Why don’t you come and see me sometimes?
Firstly, the question could be understood as the questioner complaining about the person being asked or his/her long absence. An appropriate answer could be as follows:
Huh?! I just went to yours three days ago! It’s about you to visit me!
Secondly, we could understand the opening question as an invitation to visit the questioner(s):
Oh yeah we could have a nice dinner together! What about tomorrow evening?
Speaking is in need of interpretation. Only the second turn “opens a meaningful register of possibilities of communicative connections, from which the second turn then selects one or the other”, as Buchholz (2013, p. 101) writes. These two speech moves form a sequential gestalt. The alternative perspective on psychotherapy that we can derive from this – instead of a technical input and an output that necessarily follows from it – is to emphasise the reciprocal interpretation of the participants in interactions.
Instead of the medical-technical basic understanding of psychotherapy, we propose an alternative basic understanding of psychotherapy, the interactional basic understanding of psychotherapy. In this sense, i) we would learn to trace the conversational traces left by both participants in the mutual production of the therapeutic event through their conversational contributions and ii) we would be able to understand theoretical concepts such as interpretation, countertransference, working alliance but also the making of diagnoses, determining the length of a therapy etc. in a conversationally visible and verifiable way with technical help.
An illustration of this interactional perspective on medical communication comes from three American conversation researchers (Heritage and Maynard, 2007, Heritage and Robinson, 2011) who have devoted years of research to medical communication. Among other things, they have been interested in how patients actually talk to doctors and vice versa.
They found that typically after 20 seconds doctors interrupt patients and ask questions. When asked about this, doctors reply that they have more expertise and can therefore finish more quickly. You guessed it: the average initial consultation actually lasted 15 minutes.
The researchers trained doctors to wait for the communicative gestalt to close, which typically took 1.5 minutes of speaking time. This reduced the number of follow-up questions from doctors, as patients were able to address the most important issues more quickly than doctors would otherwise have had to ask.
When ending conversations, the doctors asked the question “any” or “some more problems”, which has a completely different effect: With some more problems, the doctors received 2.5 times more descriptions of problems; only superficially do doctors ask a similar question, implicitly saying something about the expectation of wanting to hear more descriptions or not. Because any has a negative connotation in English and tells patients that they would rather not hear anything more.
Tiny details make a big difference and so-called interventions have effects that are completely unclear to those involved: “Anyone who drives a research programme based on the idea that one can determine the effects of independent variables (x) on a group of dependent variables (y) with probability (z) must reckon with the possibility that they do not even know for sure which independent variables they have actually brought into play” (Buchholz, 2013, p. 92).
Because it fits so well with the current discussion, a final example from Döll-Hentschker and colleagues (2006), who asked about criteria for frequency and setting agreements in psychoanalytic treatments. The study included 155 patients. When asked about criteria, the authors came to the surprising conclusion:
“No diagnostic criteria could be identified that would have necessarily led to treatment with a certain frequency” (translated by JUNKTIM, ibid., p. 1131).
In terms of conversation analysis, this brings shared implicit knowledge about therapy into the researcher’s view: The agreement is about a mutual recognition of this implicit knowledge that both have of each other and which setting would be conducive to this.
Conclusion: Instead of assigning specific interventions to disorders, whereby only one treats the other, Balint’s (1976) patient-centred medicine becomes acceptable again: therapy can be understood as negotiation, agreement and mutual regulation.
For more than 20 years, psychotherapy has been an integral part of the health care landscape and the previous approaches to solving problems for patients and therapists tended to create new problems because they were designed from a medical-technical perspective. We plead for alternative interactional perspectives on psychotherapy in order to better reflect the needs of the actors and to actually work on them. The TK study (Wittmann et al. 2011) recently showed that this is economically worthwhile: “every euro invested in psychotherapy leads to a saving of about three euros within one year” (see Benecke 2021). The research situation on this also clearly shows for the current discussion on diagnosis-related standardised treatment packages (Amendment No. 49 or 44 to the GVWG) that frequency does not depend on diagnostic criteria, it is not decided on a disorder-specific basis, but is the result of negotiation processes of the participants. Benecke also comes to this conclusion: “This in turn is due to the fact that diagnoses in the field of mental disorders are purely descriptive (certain combinations of symptoms in each case) and say nothing about which mental processes cause these symptoms”. It is not scientifically justifiable to base the duration, frequency and setting of a therapeutic treatment on diagnostic criteria.
We at JUNKTIM e.V. want to promote the importance of examining the actual therapeutic interactions and letting their analyses in turn flow back into the therapeutic practice that produces them. All in all, an interactional perspective on psychotherapy benefits not only the actors, but also the policy-makers, as it ties the already productive therapeutic services back to them. We would like to see an institutionalised exchange on this and plead for the research connection to the G-BA at least in the sense of patient participation.
Media
Here is a small selection of journalistic reactions to Amendment No. 49 and 44 to the GVWG (German language only):
Researcher perspectives
A small selection of research perspectives on Amendment No. 49 or 44 to the GVWG (German language only):
Alternative perspectives (English language):
Therapeutic advocacy groups
Here is a small selection of reactions from therapeutic advocacy groups to Amendment No. 49 and 44 to the GVWG (German language only):
Post scriptum
We can link the sequential shape that builds up from two successive moves as an idea with the time that the development of a psychotherapy takes as a whole and whoever likes ends up with the little wisdom of Beppo street sweeper:
“You see, Momo,” he said, “it’s like this: sometimes you have a very long road ahead of you. You think it’s so terribly long, you can never make it, you think.”
He looked in silence for a while, then continued:
“And then you start to hurry. And you hurry more and more. Every time you look up, you see that what lies ahead is not diminishing at all. And you try even harder, you get scared, and in the end you are completely out of breath and can’t go on. And the road is still in front of you. You can’t do it like that!”
He thought for some time.
Then he continued: “You must never think of the whole road at once, do you understand? You just have to think of the next step, the next breath, the next broom stroke. And always just the next one.”
Michael Ende, Mom