The Challenge to Psychoanalysis and Psychotherapy

Germany and Austria, Part 1

‘Psychoanalysis has become part of our intellectual history though historical circumstances in Germany did lead to an interruption of this tradition. During the Third Reich, the works of Freud were inaccessible to most Germans, and the science he had founded was outlawed. Jewish psychoanalysts shared the fate of all Jews in Nazi Germany and the occupied territories of Europe’ (Thomä and Kachele 1987, p. XVIII).

After the Allied forces liberated Germany and Austria from Nazi terror, the future of psychoanalysis was near impossible to predict. No one would have assumed that 50 years later the psychoanalytic movement again would have spread throughout the German-speaking parts of central Europe. In Austria, Switzerland and Germany, the present state of psychoanalysis as a clinical discipline reflects a long period of growth; the status of psychoanalysis as a theory of culture however is widely debated (Bruns 1994). In Germany the quantity of training available has been especially enlarged since the 1970s when the decision was made to confer the job of training analyst to younger members as well. At present the demand for psychoanalytic training too often finds its limitations in the sheer quantitative restrictions of training facilities in the institutes of the IPA (International Psychoanalytic Association) affiliated German Psychoanalytic Association and in the non-IPA affiliated institutes (partially organized within the German Psychoanalytic Society (DPG) or in the Deutsche Gesellschaft für Psychotherapie, Psychosomatik, Psychoanalyse und Tiefenpsychologie (DGPT), and other more other more recently founded psychoanalytic groups of only local relevance) throughout the country. The same holds true for Austria, where not only the Vienna psychoanalytic Association (by Aichhorn) but also the ‘Wiener Arbeitskreis fur Tiefenpsychologie’ (by Caruso) were (re)founded after the end of the war. The latter initiated study groups in other cities of Austria, whereas the influence of the IPA-affiliated Vienna Psychoanalytical Association remained restricted to the capital. The 27th International Congress of Psychoanalysis (1971) led to a change in the public opinion (Huber 1977) which stimulated the scientific training activities of both societies and the influence of psychoanalysis onto medicine.

This growth is embedded in the wider sphere of influence psychoanalysis has gained not only within medicine but also within the post-war German-speaking culture. This is more clearly reflected by the leading psychoanalytic journal Psyche selling 7000 copies each month. The topics of this journal cover not only clinical but also theoretical and applied psychoanalytic themes derived from the fields of psychology, sociology, anthropology and philosophy (Kachele, Ehlers and Holzer 1993). Besides Psyche there are other flourishing psychoanalytic journals. Also from the 1950s dates the empirically-oriented Zeitschrift für Psychosomatische Medizin und Psychoanalyse (Journal of Psychosomatic Medicine and Psychoanalysis), which reflects in its publication policy the academic institutionalization of psychoanalytic-oriented psychotherapy and psychosomatics. In 1985, when the IPA international congress took place in Germany for the first time after the war, a new psychoanalytic journal was launched bridging in the editorship the quite substantial post-war divide between the two psychoanalytic groups DPV and DPG. The Forum der Psychoanalyse hopes to re-unite the two psychoanalytic camps, understanding the dissociation of psychoanalysis in post-war Germany as compromise and symptom formation (Ermann 1985, p. 1). The growing awareness of Freud hagiographies no longer being the sole object of psychoanalysis paved the way for a journal devoted solely to the history of psychoanalysis (Luzifer-Amor: Zeitschrift zur Geschichte der Psychoanalyse, vol. 1,1988).

A large number of books have appeared that underscore the reception of psychoanalysis in many intellectual quarters for which A. Mitscherlich was a true one-man’s army (see the Freud centennial events organized by Adorno, Horkheimer and Mitscherlich in Frankfurt (Adorno and Dirks 1957). Though no longer as prevalent as in the 1970s when the Frankfurt school of philosophy, led by the marked leadership of Habermas (1971) and Lorenzer (1970, 1974), shaped the discussions it still continues on a smaller scale in cultural-philosophical discourse (Lorenzer 1986; Marquard 1987).

The evolution of the psychoanalytic-oriented psychotherapy care system
Any relevant statement about the future of psychoanalysis in Germany that wants to go beyond the ivory tower perspective of pure psychoanalysis as a cultural theory (Adorno 1952), but wants to evaluate the transgenerational fertility of psychoanalysis as a clinical discipline, has to take into account the process of medical institutionalization of psychoanalysis in Germany. More than the Anglo-American world struggling with the widening scope of psychoanalysis (Freud 1954), the German psychoanalytic movement in the immediate post-war era was confronted with numerous consequences of the long years of isolation which became apparent after the war. Some of them were based on theoretical developments that boasted to be new and original and which they partially were (Schultz-Hencke 1951; Thoma 1963, 1969) and which led, soon after the war, to a split in the psychoanalytic movement which still exists. Others were due to the urging necessities of caring for segments of the population that would not approach classical psychoanalysis even if it were available. Only in Berlin were these activities supported by what became the Communal Health Insurance Company (Allgemeine Ortskrankenkasse). It marked ‘the first step in the recognition of neurosis as an illness by a German public institution in Germany. For the first time, one of the institutions in the social insurance system paid the cost of psychoanalysis and other psychotherapeutic treatment’ (Dräger 1971, p. 267).

After more than 20 years of dedicated clinical work the public health insurance organizations honored the psychoanalytic contributions to the care of patients (see below). This synergy between psychoanalysis and the public health insurance system reflects the great moral and intellectual impact that the psychoanalytic movement on the German post-war society has had and—so we predict—will continue to have in Germany, even in the wake of behavioral medicine as a new paradigm. For better or worse, Freud’s 1919 Budapest manifesto has found a receptive society—a society that not only listened to the voice of the intellect of Freudian theory but also followed Bismarck’s forced social security measures by regulating psychotherapy.

Another factor that has shaped the impact of psychoanalysis into medicine resides in a tradition of an anthropological-oriented psychosomatic approach to medicine. Von Weizsacker’s studies on pathogenesis (1935) mark the beginning of a cross-fertilization between this philosophical-oriented approach to medicine and psychoanalysis. His famous dictum that ‘psychosomatic medicine will be a psychoanalytic one or it will not be’ has opened an inroad of psychoanalytic ideas that was most successfully pursued by Thure von Uexküll and his collaborators (Uexküll 1963, 1994). This melting of different strands of intellectual development into the establishment of a medical-based field for the practice of psychoanalysis and its derived analytic psychotherapies may be not unique to Germany, but, in its consequential course, it seems to be quite special.

The beginning of this process in post-war Germany can be traced by the establishment of quite a few institutions with a psychoanalytic orientation providing outpatient and inpatient treatments:

  • the Central Institute of Psychogenic Disorders (Zentralinstitut für psychogene Erkrankungen) in Berlin, supported by the local general insurance company (Versicherungsanstalt Berlin), was established in 1946
  • a psychosomatic-psychotherapeutic hospital for internal medicine, directed by Curtius, was established in Lübeck in 1946.
  • a special hospital for analytic psychotherapy in Göttingen 1949 by Kühnel and Schwidder
  • the hospital for psychogenic disorders in Berlin established in 1948 by Wiegmann
  • in 1950 a special ward for (private) patients was added to the university hospital for internal medicine in Hamburg by Jores
  • the Psychosomatic Hospital in Heidelberg established in 1950 by V. von Weizsacker and A. Mitscherlich with the support of the Rockefeller Foundation
  • a few years later, some more institutions were established at universities like Freiburg (1957), Giessen (1962) and Mainz (1965).

Though all these institutions provided analytic psychotherapy and supported the development of psychoanalytic training institutes, they were often termed ‘psychosomatic’ so as to avoid interference with the psychiatrists that also claimed to provide psychotherapy.

A decisive change in the medical curriculum was achieved in 1970 when the training regulations (ärztliche Approbationsordnung) now included, besides medical psychology, the new field called ‘Psychosomatic Medicine and Psychotherapy’. This finally led to the institutionalization of fully-fledged independent university departments at 18 (of 22) faculties for medicine. They were, and still are, all psychoanalytically oriented! However, we expect a change in the very near future.

The development in the other part of Germany was quite different. Immediately after the Second World War, some analysts trained in the Berlin Reichs-Institut worked at the ‘Institute for Psychological Research and Psychotherapy’. The impact of Soviet medicine, especially of Pavlovian reflexology, led to a silent disappearance of psychoanalysis in the vocabulary of East German psychotherapists (as documented by Geyer). In contrast to the direct state-imposed banishment of psychoanalysis under the Nazi regime there was never an official indictment of psychoanalysis. However, the strict organization of societal rule in East Germany made people become acutely aware that psychoanalysis was not part of the cultural pattern of the German Democratic Republic.

The deficits were hardly compensated by private reading circles that began to work in the 1970s. In some church-owned psychiatric hospitals like the Psychiatrischen Bezirkskrankenhaus Uchtspringe, some interests in psychoanalytic topics were maintained that inspired the training of practitioners in Balint-group work.

The dominant figure of GDR psychotherapy, R. Hock, developed an amalgam of psychodynamics and a social-psychology group therapy system that was successfully implemented in practically all of East German outpatient and inpatient facilities.

Soon after the fall of the Berlin wall, exchange among East and West started with great enthusiasm and resentment from both sides at the same time. Meanwhile, new local training institutes in Leipzig, Halle, Dresden and Rostock have been formed under the regulations of the insurance schema described below (Geyer 1992).

The post-war evolution in Austria started in quite a similar way. Due to new theoretical viewpoints (i.e., Caruso 1952), the psychoanalytic movement split after the end of the war and, in 1950, the Vienna Communal Health Insurance Company (Wiener Gebietskrankenkasse) started to pay for psychotherapeutic treatment. The institutionalization of psychoanalytic psychotherapy in medical care developed more slowly, however, in 1971 the first, and up to now the only, institute for depth-psychology and psychotherapy was founded (with H. Strotzka as chairman) at the psychiatry university clinic of Vienna, and from 1972 to 1979 a chair for psychoanalysis and clinical psychology with L. Caruso as head was established at Salzburg University. However, the momentum did not last. In 1979, after the death of Caruso, the chair for psychoanalysis was filled by an experimentally-oriented Behaviour-Psychologist and the chair for depth-psychology at Vienna University has been vacant since 1987.

The impact of the 27th International Congress of the International Psychoanalytic Association (IPA) in 1971 also left its mark on public opinion in Austria (Huber 1977). This not only strengthened the position of the traditional Viennese Society but also instigated the establishment of non-IPA study groups in regional centers like Innsbruck and Graz.

The development of professional institutionalization shows some parallel to the German situation. In 1991 a law was established for regulation of the training of psychotherapists. More than a dozen therapeutic orientations are accepted and membership in professional organizations may be acquired by many (Meyer et al. 1991). For this reason, psychoanalysts now are a real minority group among psychotherapists in Austria. In 1995, out of 3633 recognized psychotherapeuts (55 per 100,000 inhabitants), only 313 are fully-trained psychoanalysts.

Austria is probably the only country having a banknote with Freud’s portrait. The integration of psychoanalysis into university medicine and psychology and into the health care system, however, is clearly poorer than in Germany and other western countries.

The German psychotherapy delivery system
The recognition of neuroses as illnesses (im Sinne der Reichsversicherungsordnung, see Faber 1981) was a precondition for the inclusion of the so-called standard psychotherapy in the program of the major health insurance companies in 1967, followed by other public organizations (Faber and Haarstrick 1994). Some limitations were imposed by the obligations of the public and private health companies. In Germany the health insurance system exists to enable necessary outpatient and inpatient medical treatment at the time of need for people from all strata of society, regardless of their financial situation. Apart from a few special circumstances, the patient pays no more than his regular insurance premium (approximately 14% of his income). Thus the legal constraints do not permit the health insurance companies to demand from the patient any direct contribution toward the costs of psychoanalytic (and today, also, of behavior) therapy. As nearly all patients consulting a psychotherapist have medical insurance covering different forms of psychotherapy, these regulations have a powerful impact on the psychotherapy service delivery system.

The system of providing psychotherapy is regulated by a set of agreements between Kassendrztliche Bundesvereinigung (KBY, the national corporate organization of physicians regulating matters of public health—i.e. the payment of medical care) and the health insurance companies. The system of third-party payment is explicit about the fact that the patient makes no direct payment. Instead, he formally asks, by way of the therapist writing a detailed report, the KBY to cover the costs for treatment. A body of peer reviewers examines the claim and, if positive, the therapist receives his fee via the local branch of the KBY. However, the patient does have a substantial monetary interest in this transaction since he pays a fair proportion of his earnings to this health insurance company as cover for general health care, including the eventuality of an illness whose costs would be too great for the average individual to pay alone. A typical person insured with one of these public companies pays about DM5000 (approximately $3125) annually. There are no further charges at time of use. It should be emphasized that the patient’s right of legal redress is directed not at the state but at the health insurance company, an arrangement dating back to insurance regulations implemented by Bismarck. The German social insurance system is supervised by the state but it is not a national health service.

The patient knows how much is deducted from his salary or wages as his health insurance contribution and he can calculate how much he has paid in over the years and how often he has availed himself of services. He has a free choice of doctor. Just as the public health insurance companies together form a corporate entity, all medical doctors (and medical psychotherapists, but not psychological psychotherapists) are members of the KBY.

The fees for psychotherapists’ services, as for all doctors’ services, are negotiated between these two corporate organizations and have to be recognized by the federal health administration. Obviously, the agreements on the fee rates for medical services involve compromises in which political factors playa part and the general economic situation must be considered. Indeed, in many respects the specific regulations covering the psychoanalytic and behavioral psychotherapies, including the guidelines on payment, represent such a compromise.

Practitioners trained in psychoanalytic therapies are now in a position to offer the following kinds of treatments to their patients, reaching 90% of the German population that are members of the general insurance system (based on Faber and Haarstrick 1994):

  1. Initial interview and evaluation—up to 6 sessions
  2. Psychodynamic short-term therapy—up to 25 sessions
  3. Psychodynamic middle-term therapy—up to 50 sessions
  4. Psychodynamic long-term therapy—up to 80 sessions
  5. Psychoanalytic therapy—up to 300 sessions

Similar regulations are available for psychodynamic and psychoanalytic group therapy and special plans have been made for the treatment of children. In recent years behavior therapies have also been included in these regulations.

The following figures on the numbers of physicians of psychologists trained in some more or less extensive way in psychoanalytic (oriented) therapies (the plural is ours!) practising with these insurance plans were cited by Meyer et al. (1991) for 1990:

  • Medical psychodynamic and -analytic therapists: 3895
  • Psychological psychoanalysts: 1237
  • Psychoanalytic child and adolescent therapists: 740
  • Candidates in the last years of training: 1068
  • Psychological behavior therapists: 1360

Figure 4.1 represents the growth of the psychotherapy profession over the years 1982 until 1990.

These practitioners provide a mean density of care of 11.5 psychotherapists per 100,000 inhabitants. However, no figures are available on the share of non-insurance licensed private financed analytic practice. For all our knowledge, most of this deals with the training activities of senior analysts as all groups have to undergo some amount of self-analysis or self-therapy. However, this statistical mean is composed of quite diverse regional levels of density of care: in Frankfurt there are 50, in Berlin 30 and in Saarland 5 per 100,000 inhabitants.

An additional unique feature of the German psychotherapy delivery system has to be described. As our short historical account may have shown, the beginnings of this psychoanalytic-oriented field of psychotherapy was closely connected to providing inpatient facilities. As Schepank (1988), with many historical details, makes clear, this trend has been increasing since the 1970s when large hospitals established for the treatment of chronic somatic diseases like tuberculosis had to find a new clientele. Psychosomatic medicine turned out to be a comparatively cheap medicine and thus financially attractive for the owners of rehabilitation institutions. Figure 4.2 shows the steeply rising numbers of beds for psychotherapy/psychosomatics in the so-called rehabilitation segment of medical care and the less pronounced growth of beds in general hospitals (Lachauer et al. 1991).

The more than 8000 beds for short-term inpatient psychotherapy are officially provided for rehabilitative aftercare for somatic conditions like cardiac, pulmonary, orthopedic, dermatologic complaints and so forth. Given the large percentage of patients suffering from functional somatic complaints, the system of inpatient rehabilitation has over the years transformed into a system of inpatient psychodynamic-oriented psychotherapy; in recent years behavioral approaches also have successfully moved into that field and today about 25 percent of the hospitals operate within a behavioral frame. Most of these inpatient facilities are still working under the administrative-financial regime of rehabilitation providing only up to six weeks of intensive multimodal psychotherapy. However, some institutions are officially recognized as psychotherapeutic hospitals, thus being able to provide quite intensive psychoanalytic inpatient treatments lasting up to nine months (i.e. Psychotherapeutic Hospital Stuttgart (Schmitt, Seifert and Kachele 1993)). The patients taking advantage of these inpatient care facilities tend to be more sick than an outpatient clientèle and/or their motivation for change, or, to use a behavioral term, their illness behavior often would not lead them to seek help as outpatients. Most often these are chronically ill psychosomatic and psychoneurotic patients who do need some form of integrated psychosomatic, holistic treatment. The problem with this inpatient system is in the lack of systematic adequate aftercare as these patients are admitted to the therapeutic institutions from all over Germany.

Though this system of care—unique in its extension per capita of the population offers complementary treatments for a segment of the suffering population—that otherwise clearly would be not cared for, for scientific reasons one has to raise the issue of whether this system of inpatient care follows the bad strategy of treating patients too late and too often as inpatients. The scientific issue of whether it would be possible to treat all these patients as outpatients, if the system of patient care would be in a position to really draw these patients into treatments, has not been settled. Therefore, Meyer et al.‘s (1991) opinion decrying it as a ‘mis-allocation of public resources’ might be too strong a statement because the development of inpatient psychotherapy also represents an outgrowth of public acceptance of psychotherapy and especially of psychoanalytic-oriented psychotherapy’ (Kächele and Kordy 1992). This is underscored by two recent developments in the institutional configuration of psychotherapy within the German medical system.

In 1987 a new tool called ‘basic psychosomatic care’ was introduced to encourage general practitioners to use more psychological competence in their daily work with patients. It demands a minimal training in psychodynamics to increase competence in dialogue and diagnosis and to add some basic psychotherapeutic interventions to daily practice. It is financially rewarding and seems set to become a successful tool for raising the level of awareness of the needs of the many patients suffering from functional disturbances. In 1989 one-third of all practitioners had been trained in this new minimalistic medico-psychological device. However, it is used infrequently (twice a week in less than 10% of patients). Epidemiological studies report 30 per cent of the patients of a general practitioner as having psychosomatic disturbances (Meyer et at. 1991).

In 1993 a new specialty for psychotherapeutic medicine was created which will further enhance the historical process of generating the field of ‘psychosomatic medicine and psychotherapy’ that began right after the war. Until then, psychoanalytic therapies within medicine were based on mutual agreements that could be easily altered. With the establishment of a specialty field, besides and independent from psychiatry, a major breakthrough will have been achieved. Even if this field is not by definition a psychoanalytic specialty, the historical dominance of psychoanalysis within German psychotherapy makes it quite clear that the majority of ‘specialists for psychotherapeutic medicine’ will be trained by psychoanalysts and some of them also will promote their own training to become full psychoanalysts. The historical blindness of German psychiatry in denouncing psychoanalysis and neglecting the practice of psychotherapy has led to the creation of a unique field. Ironically, at the same time that this new specialty was established, German psychiatry has officially rediscovered that psychotherapy should be a routine part of psychiatric training—this resulted in an extension of the specialty title as well, now called ‘psychiatry and psychotherapy’. It is most likely that psychiatric training will orient itself towards the more behavioral-oriented treatment techniques or compromise for the new star at the horizon of short-term treatments for ‘Interpersonal Therapy’ (Klerman et al. 1984). This alliance of so-called empirically-based psychotherapies with psychiatry in Germany also constitutes the major challenge to the psychoanalytic dominance in the field. Meanwhile, the grown-up field of clinical psychology is establishing itself as a new profession in psychotherapy (Grawe, Donati and Bernauer 1993) and will thus become the major rival for psychoanalytic therapies.

BRD 1994 cases treated within the insurance schema

Psychodynamic Psychotherapy
a) short-term (up to 40 sessions): 124,523
b)long-term (up to 100 sessions): 85,681

Analytic Psychotherapy (2-3 sessions per week): 29,435

Behavioral-oriented Psychotherapy: 98,532
a) short-term (up to 25 sessions): 65,117
b) long-term (up to 80 sessions): 33,415

Recently analytic psychotherapy has faced a limitation in terms of weekly frequency of sessions (Thomä 1994). Only two or three sessions per week are allowed within the insurance-regulated system, up to a maximum of 300 sessions; four-times-a-week analysis is only allowed for a limited period of time due to medical reasons. The lack of substantial scientific-based evidence of the impact of sessions’ frequency on outcome shows repercussions (Grawe et al. 1993; Kachele and Thomä 1994). However, the psychoanalytic-oriented treatments make up for the majority of insurance-based treatments.

The current main topic of debate within the German psychotherapy care system is centered around the issue of whether or not clinical psychologists trained in one of the two legally accepted therapeutic orientations (psychoanalytic and cognitive-behavioral) should be given the status of independently working psychotherapists inside the medical system. Up to now, each psychologist working as psychotherapist has to consult with a medical doctor on every case. If the psychologist would be given an independent status, a major inroad into the medical monopoly of health care providers would be achieved.

The development in Austria shows some similarities and some important differences with respect to professionalization of psychotherapy. Psychoanalysis has never been integrated into the medical care system and into the universities to the same extent as in Germany. However, in 1991 Austria was the first European country where a law was enacted to regulate the training of psychotherapists and the psychotherapeutic practice as a new profession. Being a physician or a psychologist is no longer an assumption for being trained in psychotherapy. Private organizations and societies can offer a three-year curriculum in psychotherapeutic training without any formal scientific feedback or integration into medical or psychological studies. Beside psychoanalysis, more than a dozen psychotherapeutic schools and methods are recognized, regardless of their effectiveness (Sbandi et al. 1993), and this new profession is open to members of all social professions (see Meyer et al. 1991). That is the reason why psychoanalysts and even psychodynamic psychotherapists are a minority among Austrian psychotherapists. In 1993,3600 psychotherapists (55 per 100,000 inhabitants) were recognized by the health administration, about 300 of whom graduated from psychoanalytic training. Actually, the Austrian insurance companies only refund about 30 per cent (300 AS) when the psychotherapy is supplied by a member of this new profession and almost 100 per cent of the costs when the patient is treated by a medical doctor.