Digital Applications in Psychotherapy and Developments in the Corona Crisis
Goals for further professionalisation of psychological psychotherapists in Europe
International video conference on 29 September 2020
The corona pandemic and the measures associated with it have an impact on the psyche of all people. The pandemic has brought about extreme changes in the working and living situation for large sections of the population, with associated stress levels and insecurity. The work situation for psychotherapists in particular has also changed drastically, especially during the period of the lockdown. In the corona crisis, psychotherapists have a special responsibility for the care of mentally ill or strained people.
This was the general tenor of the international video conference "Digital Health Apps in consideration of the corona crisis as well as developments and aims for further professionalization of the psychological psychotherapists in member countries", held by the German Chamber of Psychotherapists (BPtK) in cooperation with the members of the Network for Psychotherapeutic Care in Europe (NPCE) on 29 September 2020. The event was attended by Nikolaus Melcop, Vice President of the BPtK, and by experts from the NPCE from Austria, Cyprus, Hungary, Ireland, Italy, Lithuania, Poland, Portugal, Romania, Switzerland and the United Kingdom. Since 2011, clinical psychologists and psychological psychotherapists from 20 European countries have been in regular contact via the NPCE to exchange information on the care situation of mentally ill people. They also discussed ways to improve care and to further develop the profession in their countries.
During the video conference on 29 September 2020, the focus of the first round of discussion was on the status and framework conditions of internet-based interventions such as health apps, digital treatment programmes and video consultation in the work of the psychotherapist.
How has Corona changed therapy?
It became clear that the corona pandemic has accelerated the spread of digital applications and video-based psychotherapy. The development of digital structures is now taking place everywhere, but usually only a few individual models have been implemented, e.g. for specific target groups. They are not yet part of a catalogue of services financed by statutory health insurance.
There was consensus among the participants that digital applications are effective for certain target groups while they cannot replace the psychotherapeutic session in direct personal contact and should not be used without professional guidance. It is not a question of either/or, but rather of the correct use of digital media on a case-by-case basis and the supplementation of established therapies with new digital possibilities.
Overall, corona has increased public awareness of the importance of mental health and psychotherapy as an effective and helpful intervention. The crisis triggered by corona is thus also an opportunity to make more visible the contribution that psychotherapists can make to keeping people healthy. This was the conclusion of the participants.
Cyprus (Ph.D Maria Karekla)
At the beginning, Maria Karekla from the University of Cyprus presented the results of a Europe-wide survey on changes in everyday psychotherapeutic work during the corona crisis. 8858 psychologists and psychotherapists from all over Europe were included in the survey. 82 percent of them already used digital therapy components or intended to do so in the near future. For 66 percent of them it was the first time. Karekla pointed to the problems involved: only 9 percent of respondents had received prior instruction and (free) internet access for those seeking advice and the privacy of treatment was not always guaranteed. Moreover, remuneration was often not regulated. In her home country Cyprus itself, the problems are still considerable. On the other hand, there are positive effects. Feedback from clients indicated that the video consultation is considered to be comparably effective. As a result of the study, recommendations were formulated for psychotherapists, for health services, supervisory authorities and for app developers.
Lithuania (Elena Gaudiesiute)
In Lithuania, the country‘s more than 100 public mental health centres provide assistance even in times of corona. Since the beginning of the year, free psychotherapeutic sessions have been part of the public health services. As a result of corona, the number of people seeking advice in face-to-face contact has decreased, while a newly established hotline was used by thousands. Elena Gaudiesiute underlined that the development of internet-based interventions is making good progress in Lithuania. There are many good initiatives, but the effectiveness of the various apps used to address mental health problems needs to be evaluated more and in a scientific manner. Overall, the care situation of mentally ill people was still problematic, with only 1 percent of health care expenditure being spent on medical health centres offering psychotherapeutic services.
Portugal (Rosa Castro André and Dr Jorge Gravanita)
The internet expert Rosa Castro André, psychotherapist at the NOVA University in Lisbon, presented the project she developed, an internet-based hotline. It is currently being tested as a prototype and also contains a special tool for Covid 19 cases. Although a hotline run by the national health service already exists, this platform is too cumbersome, said Rosa Castro André. The new platform was developed in exchange with users, students and psychologists and incorporated their experiences and expectations. It was a challenge to make also dynamic psychotherapy and cognitive behavioural therapy digitally accessible. She stressed that digital applications are neither more nor less effective than a personal psychotherapeutic session but work in a different way.
Dr Jorge Gravanita, President of the Portuguese Association of Clinical Psychologists (SPPC), complained about the largely lacking political regulatory framework for psychotherapy in his country: no binding regulations for health apps, no definition of psychotherapy and no reimbursement for psychotherapeutic services in the public health system exist, unless when prescibed by a psychiatrist. Psychotherapists still had too weak a voice in health policy, both at the national and the European level.
Ireland (Vasilis S. Vasiliou)
Vasilis S. Vasileiou, a researcher at University College Cork (UCC), underlined the importance of targeting aid in times of corona such as students at higher institutions who are using illicit drugs. He presented the MyUSE app, which he co-developed and evaluated at University College Cork (UCC), Ireland, and which is intended to enable people to deal with illicit drug use, but can also be used for other mental health platforms. He showed how personalised feedback based on the risk level of the user can be employed to interactively develop individual goals and customised risk reduction activities as well as to support the implementation of risk-avoiding behavioural strategies. According to Vasilis S. Vasileiou, a central challenge is data management and the prevention of abuse.
Germany (Dr phil Nikolaus Melcop)
For Germany, BPtK Vice President Melcop related that since October 2019, psychotherapeutic counselling in the form of video consultation has been remunerated to a certain extent by the statutory health insurance companies. Only software certified in terms of data security and protection of privacy may be used. In principle, 20 percent of consultations can be carried out via video; due to corona, this restriction has been temporarily lifted. Health apps are now being tested by the competent authority, the Federal Institute for Drugs and Medical Devices (BfArM), and a list of them are made publicly available. These certified apps may then be prescribed by psychotherapists. The BPtK demands that apps are only used after an indication has been given and with the assistance of psychotherapists or doctors. The costs are covered by the statutory health insurance.
Hungary (written report by Máté Kapitány-Fövény)
In Hungary, during the first wave of the COVID 19 pandemic, the quarantine regulations allowed for Skype counselling by listed psychotherapists. Máté Kapitány-Fövény of Semmelweis University in Budapest, also clinical psychologist at NyírőGyula National Institute of Psychiatry and Addictions, underlines in his report the effectiveness of combining self-management interventions and therapeutic guidance. E-health interventions offer useful but limited possibilities; severe mental disorders should be treated in personal psychotherapy and only digital health apps based on effectiveness studies should be used. In Hungary, both programmes developed in international cooperation and nationally developed e-health tools are available. The latter are now to be specifically promoted within the framework of a call for proposals by the Hungarian Ministry of Research.
Romania (written report by Roman Viorel)
The Covid 19 pandemic has shown that e-health interventions are accepted. Many psychologists continued online consultations even after the relaxation of corona measures, although personal therapy was allowed again. Roman Viorel, who has been working with the Alliance for the Fight against Alcoholism and Drug Abuse (ALIAT) since 2002, which offers online counselling and a self-help app, underlines in his report the advantage of greater confidentiality of online psychotherapy. People in Romania are less anxious online than if they had to go to psychiatric institutions for help. However, Romania is not yet sufficiently prepared for digital interventions, there are no guidelines and no professional standards. The biggest obstacle is the lack of funding.
Poland (Iga Jaracewska)
Iga Jaracewska, who is a trainer at the Polish "Motivational Interviewing Network of Trainers", explained the situation in Poland. Corona opened up new possibilities, and efficient and effective online treatment tools, e.g. for anxiety disorders, have been developed very quickly. Jaracewska underlined „online tools are useful, complementary instruments in therapy, they can shorten waiting times and are also accepted by clients. However, the most important part of any therapy is the quality of the relationship. The personal face-to-face conversation must remain ensured.“ The fact that people were offered help quickly and free of charge out of solidarity on the part of the therapists greatly enhanced the reputation of psychotherapy in Poland.
Austria (Karin Kalteis)
Karin Kalteis from the board of the Association of Austrian Psychologists (BÖP) reported that so far only a small part of psychotherapists in Austria uses digital health apps. At university level, some research projects are underway, but there are no official guidelines for the use of apps. Online counselling is possible in Austria on a case-by-case basis and is permitted to an unlimited extent until the end of the year, possibly longer, due to corona. A special competence in online counselling is required. Covid 19 has increased client acceptance of treatment via digital media. The statutory health insurances accept its use. It would be important to develop guidelines for psychotherapy via digital media.
Switzerland (Veronica Isabel Defièbre)
Surprisingly unaffected by Covid 19, psychotherapy in Switzerland is still going on, reports Veronica Isabel Defièbre of the board of the Association of Swiss Psychotherapists (ASP). There are no regulations for internet-based forms of psychotherapy and the health authorities see no need to adapt the law governing the psychological professions. Video consultations remain prohibited, and in the wake of the pandemic, only limited and temporary telephone counselling was made possible. Apps are not planned. However, discrepancies between the official policy, the actual counselling situation and the remuneration situation probably exist. The health insurance companies are in the process of developing their own apps in cooperation with colleges and universities, e.g. for depression and anxiety disorders. Many patients would also like to have means of communication other than personal sessions, but generally prefer personal sessions to virtual forms of counselling, Defièbre says.
Procedures and quality standards differ greatly in the various countries
The reports show that the challenges in developing digital interventions and dealing with the negative effects of the pandemic are similar everywhere. There are many examples of good practice. However, there are hardly any established structures to deal with the psychological consequences of corona. Digital applications are mainly developed by each country itself. The quality requirements are very different. They range from regulatory testing to the absence of any specifications.
According to the unanimous opinion of those involved, the prerequisites for safe and effective treatment are evidence-based programmes and applications tested for effectiveness, as well as training in their use. The effects of digital applications on the cooperation between therapist and client also need to be further investigated. Digital applications cannot replace psychotherapy in personal contact. Almost everywhere, political framework conditions with regard to quality assurance and cost coverage still lag behind the technical possibilities and also practical experiences with digital applications.
Need for action both at the national and the European level
The participants regretted that in the first phase of dealing with corona, negative psychological consequences – e.g. the isolation of older people – were not sufficiently taken into account and that incomplete health policy decisions were made as a result.
Although the perception of the importance of mental health had increased, this was not yet sufficiently reflected in political action. The access of vulnerable groups to psychotherapy must be further improved. The mental health consequences of Covid 19 should be better integrated into policies at national and European level. The network intends to work towards this goal under the upcoming Portuguese EU Council Presidency in the first half of 2021.
Professional profile of the psychological psychotherapist remains heterogeneous in Europe
The second part of the conference focused on current developments in vocational policy. The contributions of the participants showed a still very heterogeneous picture of the training, definition and rights of psychological psychotherapists in the individual European countries. The spectrum ranges from a largely lacking regulation of the professional profile, insufficient cost coverage, a lack of postgraduate internship possibilities and insufficient employment opportunities for psychotherapists in the public health system, as in Cyprus, Lithuania, Poland and Portugal, to countries with detailed statutory rights, obligations and further training regulations.
Examples of good practice from other countries could be helpful for the development in their own country, the participants said. The training system in the United Kingdom and the reform of vocational training in Germany, which came into force on 1 September, played a major role in the discussion.
In future, the structure of studies and further training for psychotherapists in Germany will be comparable to that of the medical profession, explained Nikolaus Melcop in his presentation. The training will then include a Master's degree with intensive practical and scientific qualification, a final state examination and state certification for self-employed work as a psychotherapist. The course will be followed by further training, which concludes with the professional title "Specialised psychotherapist for children and adolescents“ or "Specialised psychotherapist for adults“. This further training entitles the holder to set up a private practice within the outpatient system of the statutory health insurance. The further training will be completed in employment with appropriate remuneration.
For the United Kingdom, Lee Hogan, ((Foto einfügen)) clinical psychologist with the NHS and Assessment Director for the North Wales Clinical Psychology Programme at Bangor University, gave a detailed insight into the system of psychotherapeutic training, which is uniformly structured by the British Psychological Society (BPS), the professional association of psychologists, and closely linked to the National Health Service (NHS). This ensures various training places, remuneration within the framework of the training for three years and a scientific basis for the training through a research project in the final phase of the training. Lee Hogan emphasised the importance of inter-professional cooperation between nurses, doctors, psychiatrists and psychotherapists in the care of mentally ill people, which is well-established in the United Kingdom.
In Ireland, training structures are similar, but there is currently no professional register. However, Vasilis Vasileiou reported that a committee to deal with this issue will be set up in 2021.
In Switzerland, a revision and limitation of the legally recognised methods is currently being discussed. According to the notions of psychotherapists and also of the statutory health insurance companies, the delegation system still in force should be replaced by a prescription system. But there is still no agreement to grant psychotherapists more extensive independent rights, says Veronika Defièbre. The Swiss Federal Council could make a decision this year.
In Hungary, since February 2020, the penal code has stipulated a one-year prison sentence for those who provide psychotherapy without qualifications in the health care system. Only clinical psychologists - with and without psychotherapeutic training - are thus permitted to provide treatment.
In the case of Italy, Alberto Zucconi, ((Foto einfügen)) President of the Centered Approach Institute IACP, made the critical comment that university training is too remote from professional practice and that the procedure for recognition of training centres is too bureaucratic. Since 1998, the profession of psychologist and the training of psychotherapists have been regulated by law in Italy - around 40 percent of the 160,000 psychologists in Italy have been trained in psychotherapy - and the professional legislation provides for a chamber of psychologists. According to Alberto Zucconi, professional representation must focus more on the rights and interests of patients.
In Austria, a legal revision of the professional law has been discussed for years. The multitude of approved treatment methods is to be limited, but so far without result.
The exchange between the experts showed that - while the framework conditions for the profession of psychotherapists in Europe are very different in terms of organisational form, competences, rights and remuneration and the access of patients to psychotherapy is still often completely insufficient - psychotherapy is nevertheless well on the way to establishing itself at a high professional and scientific level everywhere in Europe. A next step could be to define uniformly the basic professional skills required to provide psychotherapy, regardless of the professional title.
In conclusion, all participants agreed that the NPCE network could continuously make an important contribution to improving the provision of psychotherapy for mentally ill people in the health systems of the various European countries and thus also at EU level.
Country report Portugal NPCE 29 Sept.pdf
Kick-off speech Dr Nicolaus Melcop
Biographies of the experts
Country reports and presentations
29 September 2020
Digital NPCE Meeting "Digital Health Apps in consideration of the corona crisis as well as developments and aims for further professionalization of the psychological psychotherapists profession in member countries"
Agenda NPCE Meeting
Psychotherapist training reformed in Germany
Graduates to be licensed and then professionally trained
The training of psychotherapists in Germany will soon be subject to new regulations. Beginning in September 2020, psychotherapists will undergo a qualification process that is comparable in structure to the education and post-graduate training of physicians.
After a foundational course of study that prepares them for their profession both practically and theoretically and that ends with a master's degree, students will become licensed psychotherapy practitioners by passing a state examination. They will then undergo at least five years of postgraduate training in the outpatient, inpatient and institutional fields.
Psychotherapists will no longer undergo postgraduate training as interns; they will, instead, be issued with a basis professional license, which will enable them to earn a salary subject to social insurance contributions. To date, Germany’s psychotherapists in training work for years without any entitlement to a salary and under precarious employment conditions, despite having obtained a university degree.
At the end of their postgraduate training, they, like specialized physicians, will receive the necessary certification to provide treatment as Fachpsychotherapeuten (specialized psychotherapists) to those with statutory health insurance.
The new regulatory reforms of the education and training of psychotherapists will ensure that patients continue to receive “a high level of professional, scientifically based psychotherapeutic care“. They will, however, also serve as the basis for psychotherapists assuming more extensive responsibilities in the future with respect to treatment, coordination and leadership in the care of mentally ill people.
Prevention of and early intervention in alcohol-related disorders
International roundtable discussion on 9 April 2019 in Berlin hosted by the BPtK
Beer, wine, and liquor are consumed in Europe more than anywhere else in the world. Young adults in particular often consume too much alcohol. Alcohol abuse leads to violence and death and increases the mortality rate by raising the incidence of numerous secondary diseases. Greater than ten per cent of all deaths in Europe are caused by alcohol abuse. Some 12 million EU citizens are alcohol-dependent, and around 9 million children in Europe live with alcoholic parents. While there are encouraging examples of initiatives to prevent alcohol abuse in some Member States, there is no effective, Europe-wide strategy in place to manage the consumption and sale of alcohol. Although psychotherapy can contribute significantly to both outpatient and inpatient care for alcoholics, it remains far too rare.
These were the key findings of a roundtable discussion titled "Prevention of and Early Intervention in Alcohol Disorders - Learning from Best-Practice Examples in Europe” held by the Federal Chamber of Psychotherapists (BPtK) in cooperation with the Network for Psychotherapeutic Care in Europe (NPCE) in Berlin on 9 April 2019. Participating in the discussion were experts from Belgium, Bulgaria, France, Ireland, Italy, Lithuania, Austria, Poland, Portugal, Romania, Hungary, Switzerland, Cyprus and Germany.
Opportunities and limitations of a European alcohol control policy
BPtK Vice-President Dr Nikolaus Melcop underlined the need for policies that prevent alcohol abuse effectively and that also facilitate the early detection and treatment of those at risk of suffering from alcohol abuse and those already ill. He contended that alcohol control policy in Germany is lopsidedly focused on education and behavioural prevention. Other EU Member States, he stated, have successfully implemented more effective alcohol control policies, including price controls, advertising bans and distribution restrictions. Yet, according to Dr Melcop, their effectiveness has been compromised by the less proactive measures of neighbouring countries. He argued that this, combined with the very high mobility of EU citizens and the interdependent nature of the EU market, necessitates complementary transnational measures.
It must, for example, be ensured that alcoholic beverages are labelled in a binding, transparent and consumer-friendly manner. Yet, the alcoholic beverage industry’s current proposal concerning ingredient labelling would satisfy neither public health requirements nor consumer protection standards as, according to Dr Melcop, little meaningful information would appear on alcohol products themselves. According to this proposal, consumers would have to go online to access further information. Dr Melcop remarked that it was foreseeable that such proposals for self-regulation would only delay the implementation of effective solutions. Public health, however, must take precedence over economic interests, he asserted.
The EU is explicitly obliged to improve public health and prevent disease. Sentence 4 of Article 168(1) of the Treaty on the Functioning of the European Union (TFEU) states: “The Union shall complement the Member States’ action in reducing drugs-related health damage, including information and prevention.” In addition and in particular, the European Parliament and the Council may, on the basis of Article 168(5) of the TFEU, adopt measures that “have as their direct objective the protection of public health regarding tobacco and the abuse of alcohol”.
In recent years, the European Parliament and the Council have repeatedly mandated the Commission to adopt a new alcohol strategy.
Panel of experts
The roundtable began with a presentation of conditions in particular Member States, as well as research findings and a number of best-practice examples. The participants then developed joint proposals for improving prevention, early detection, and treatment.
Austria (Alfred Uhl)
Alfred Uhl, deputy department head of the Competence Centre for Addiction at the Austrian Public Health Institute presented his country’s highly successful Sucht am Arbeitsplatz (Addiction in the Workplace) programme. He emphasised that the way in which people in Austria conduct themselves with alcohol had improved in recent decades and that consumption had become more moderate. He reported, however, that it was difficult to evaluate methodically the effectiveness of the particular measures taken. Dr Uhl said that it was important to pursue approaches that were non-ideological, patient-oriented, and diversified according to particular needs.
Portugal (Dr Jorge Gravanita and Patrícia António Brilhante)
Although alcohol consumption in Portugal is in line with the European average, a pattern of rising alcohol consumption amongst women and older people is a cause for concern, according to experts Patrícia António Brilhante of the Lisbon Alcoholic Unit ARSLVT and Dr Jorge Gravanita, President of the Portuguese Association of Clinical Psychologists (SPPC). They stressed the importance of including family members of those affected in therapy. Young people, they explained, require adult guidance to develop a healthy attitude toward alcohol consumption and that it is necessary to train psychotherapists in new therapeutic methods and to develop innovative programmes. They also contended that the public in all Member Countries needs to be made more aware of the work performed by psychotherapists in treating addiction and mental suffering in general.
Cyprus (Maria Karekla, PhD)
Maria Karekla from the University of Cyprus also underlined the importance of consuming alcohol in sensible quantities. Alcohol, she asserted, can be part of one’s day-to-day life without it providing any particular stimulus that can lead to its abuse. Dr Karekla stressed the importance of educating and sensitising the public better about the risks. Hospital and outpatient care, she said, are equally important to therapy, as is adequate emergency care.
Italy (Pierangelo Sardi)
“Although alcohol consumption is often downplayed, it is, in fact, responsible for more road accidents than illicit drugs and medicines. It must, therefore, be combated more effectively,” said Pierangelo Sardi, former president of Italy’s national association of psychotherapists. Dr Sardi said that the EU’s Driving under the Influence of Drugs, Alcohol and Medicines (DRUID) project had revealed how important the psychotherapeutic treatment of post-traumatic stress disorders is not only for victims but for perpetrators. He also emphasised that the confidentiality of psychotherapeutic consultations, which is assured by organising the profession into a single chamber, is an important guarantor of treatment.
Romania (Roman Viorel)
Since 2002, Roman Viorel has worked as a board member, project leader, managing director and psychologist at ALIAT, one of Romania’s leading NGOs devoted to fighting alcohol addiction and drug abuse. In addition to offering on-site professional help provided by multi-professional teams, ALIAT offers online counselling and a self-help app. “It’s important to reach out to people wherever they are – both online and in the community – and not wait for someone to come looking for help,” says Viorel. Such legal measures as the government’s zero-tolerance policy against drinking and driving and the country’s ban on drinking alcohol in public places, he said, are helpful.
Poland (Iga Jaracewska)
In Poland, the blood-alcohol content (BAC) limit for driving has been lowered to just 0.02%. Alcohol distribution and advertising are restricted. Iga Jaracewska, who among other things works as a trainer with Poland’s Motivational Interviewing Network of Trainers, proposed that information campaigns about tobacco use be employed as a model for Europe-wide measures against alcohol abuse. She explained that a value-based, non-intimidating approach to such campaigns is important.
Germany (Dr Nikolaus Melcop)
BPtK Vice-President Dr Nikolaus Melcop referred to the successes of campaigns such as Lieber schlau als blau (Better wise than drunk), which is aimed at young people, and Aktionswoche Alkohol (Alcohol Action Week), whose tagline in 2019 was “Alcohol? Less is better”. Overall, however, he felt that politicians in Germany relied too exclusively on people exercising self-control and taking personal responsibility for their actions. He reported that the introduction of effective context-related prevention measures already tried and tested in other countries, e.g. advertising restrictions, has thus far failed, due to insufficient political resonance. According to Dr Melcop, Germany’s addiction assistance system is comparatively well developed, but he said that there is still room for improvement, particularly with respect to prevention and early detection.
Ireland (Vasilis S. Vasiliou, PhD)
Ireland has the second highest rate of binge drinking in the world. Alcohol consumption and excessive drinking are also increasing among the female population. This trend has been countered by legal interventions made in 2018, such as an increase in the alcohol tax and stricter regulations concerning the distribution of alcohol. Dr Vasilis S. Vasiliou, a researcher at University College Cork (UCC), presented two best-practice examples – MiUSE (My Understanding of Substance & Alcohol Use Experiences) and REACT (Responding to Excessive Alcohol Consumption in Third Level) – both of which interactively target behavioural changes among students.
Switzerland (Veronica Isabel Defièbre)
Switzerland’s federally organised system also relies primarily on information and self-regulation. One such example is a campaign against alcohol abuse called “How much is too much?”. Considerable regulatory differences exist amongst the country’s cantons. Hence, for example, more limited opening hours in one canton simply lead people to purchase alcohol in neighbouring cantons with fewer restrictions. Veronica Isabel Defièbre of the Board of the Association of Swiss Psychotherapists (ASP) sees a need for improvement in the support provided to alcoholics in their everyday lives, for example through home visits by social workers, assisted living, and long-term psychotherapeutic treatment for chronic alcoholics.
In Belgium, alcoholic products bear illustrated warnings of the dangers of consuming alcohol for pregnant women. The country has implemented an early-detection measure that appears to be worth imitating: Physicians are entitled to refer patients whom they suspect of consuming excessive amounts of alcohol to a one-day consultation and preventive examination. The report’s authors, Dr Salvatore Campanella and Dr Hendrik Kajosch from the Centre Hospitalier Universitaire Brugmann in Brussels, stressed the central importance of changing cultural paradigms. “Drinking has a positive public image and is socially accepted in Belgium. Consuming strong beer, for example, is promoted as a sign of masculinity: ‘If you can’t beer it, you are not strong enough.’”
In Bulgaria, health legislation earmarks one per cent of all state revenues from tobacco and alcohol sales to finance national anti-smoking and alcohol-abuse control programmes. According to Svetlana Nikolova, coordinator of Bulgaria’s national drug, alcohol and gambling helpline team and Dr Svetlana Velkova, a clinical psychologist at Fracarita Bulgaria, a rehab association for addicts, the treatment of alcohol addiction is problematic in many respects in Bulgaria. They report that financial resources are insufficient, that very few alcoholics ever receive psychological counselling, and that staffing shortages prevail. The authors point out the cultural differences that exist with respect to alcohol use. “In Bulgaria, people don’t ask themselves whether they should drink but how much they can drink and stay sober.”
In Lithuania, there has been a ban on alcohol advertising in all media since 2018. Business hours for purchasing alcohol have been shortened and the legal age for purchasing alcohol has been increased from 18 to 20 years. All alcoholic beverage packaging must feature health hazard warnings, e.g. about the link between alcohol consumption and cancer. The country’s BAC limit for driving has been lowered to 0.04%. Clinical psychologist Elena Gaudiesiute remarked: “The opportunity to obtain high-quality assistance through the national health insurance system is a really positive thing. This allows people with little or no income to get the help they need, too”.
France has a well-developed, tiered treatment model, but experts Barak Raz, Dr Dominik Straub and Dr Martine Schmuck from the ROANNE addiction centre in Lyon believe that it is necessary to focus even more on prevention and on involving family members in treatment: “The existing treatment options concentrate on the individual, but often neglect the familial dimension. There is a need for further psychotherapy aimed at combating the suffering and trauma that often occurs in a family across multiple generations”.
According to Dr MátéKapitány-Fövény, Prof. Dr Zsuzsanna Elekes and Dr Zsolt Demetrovics, alcohol consumption in Hungary has deep cultural roots. The country has one of the highest rates of heavy episodic (binge) drinking and the highest rates of cirrhosis in Europe. Meanwhile, the public health insurance scheme does not cover the cost of psychotherapy. When treating alcohol abuse, the majority of health care professionals focus on drug therapy. There is also no political strategy in place, they said. In addition to heavy drinking being socially accepted to a large degree, the country’s media outlets pay no attention to the problem, the report’s authors contended.
Alcohol prices and availability
The participants agreed that moderate alcohol consumption had to be learned and that alcohol should not be readily available. Countries with higher prices and stricter tax regimes have significantly lower per-capita alcohol consumption than those where alcoholic beverages are inexpensive. Higher prices are effective in reducing alcohol addiction.
Systematically strengthening prevention
There are many good examples of how to educate people about the dangers of alcohol consumption and of how young people, in particular, can strengthen their overall mental resilience. Such measures must be implemented across the board at every stage of educational development, from elementary school to university. The universities need to be more involved in the development of such measures.
Identifying risk early and providing comprehensive care
From a therapeutic point of view, there is an urgent need to implement a screening system that would identify those who are at risk of developing an alcohol-related disorder before they do so. Such a system must also care for those already dependent on alcohol according to individual needs (i.e. in a tiered, integrated and coordinated manner) and must include follow-up care for chronic alcoholics. Treatment must not be limited to purely physical detoxification but include withdrawal and weaning therapies, as well as psychotherapeutic (and psychosocial) interventions.
From positive individual examples to a Europe-wide strategy
The discussion also highlighted that the problems and challenges are similar everywhere. In every European country, the consumption of alcohol, a legal drug, has a massive negative impact on public health. Member States offer encouraging examples of how alcohol abuse can be prevented, but there is a lack of a Europe-wide effective policy to control alcohol consumption. It is therefore important that the European Commission, newly formed following the European elections last autumn, accept its mandate to draw up a new alcohol strategy. Such a strategy could provide a framework for a structured dialogue between Member States and could also make available financial resources for the exchange of best practices amongst them. It should also support the Member States in implementing national rules and regulations and, in the medium term, implement proven management approaches across Europe.
Kick-off Speech Dr Nikolaus Melcop
Biographies of the experts
Country Reports and Presentations
Round-table discussion “Prevention and early intervention for alcohol-related harm: Learning from best-practice examples in Europe”
Europe shows the highest rate of alcohol consumption worldwide: on average, each European above the age of 15 consumes 9.8 litre of pure alcohol per year. Amongst adolescents in the agegroup of 15 to 19 years, 43.8 per cent drink alcohol regularly, with the rate of girls increasing. More than 10 per cent of all deaths in Europe are caused by alcohol abuse. Excessive drinking is a risk factor for many physical and psychic secondary diseases and increases the mortality rate in particular of people with low income. Direct and indirect costs of alcohol-related diseases are estimated at approx. 40 billion euros for Germany alone.
In cooperation with experts and members of Network for Psychotherapeutic Care in Europe (NPCE), the BPtK (Federal Chamber of Psychotherapists) plans to analyse the situation in the various European countries and consult about strategies to reduce the abuse of alcohol. Which legal regulations exist in the various countries and which factors are conducive respectively preventive to alcohol abuse? How can countermeasures such as a price increase for alcoholic beverages, restrictions on promotion, prevention programmes for adolescents, implementation of screenings as part of medical care and early treatment including psychotherapeutic interventions be promoted and be more widely applied? What happens on the EU level concerning this field and what could the European Union do in the future to prevent alcohol-related harm?
After the round table discussion, the members of the NPCE will meet to consult about perspectives and key topics of future network activities. This meeting is open to all psychotherapists interested in this initiative, including those that are no NPCE members.
Please download the invitation and agenda here
Report on psychotherapeutic care for refugees in Europe now available
The German Chamber of Psychotherapists (BPtK) in cooperation with the Network for Psychotherapeutic Care in Europe (NPCE) has undertaken a stocktaking process on the situation of care for refugees in the different European countries. The survey received also support from the European Society for Traumatic Stress Studies (EStSS). Based on a structured questionnaire, that also encouraged open comments, international experts gave feedback about treatment conditions, challenges and needed changes in the care for refugees in their country. Overall we obtained answers from psychotherapists, psychologists, medical doctors and health care managers from 14 different European countries. The responses show a need for action at the legislative, the organizational and the therapeutic level. The report includes also encouraging examples of good practices of care.
Please click here for the full report.
Psychotherapeutic care of refugees in the EU inadequate
International round-table discussion of 23 March 2017 in Berlin
hosted by the Federal Chamber of Psychotherapists
The psychotherapeutic care of mentally ill refugees in Europe is inadequate and urgently requires improvement. This was the conclusion of a round-table discussion organised by Germany’s Federal Chamber of Psychotherapists (BPtK) on 23 March 2017 in Berlin, which was attended by experts from nine different European countries and a representative of the European Commission.
BPtK Vice-President Dr Nikolaus Melcop, reported in his introductory address that a survey conducted by the BPtK concerning the psychotherapeutic care of refugees in Europe had made it easier to describe the situation in each country more precisely and to assess it better. Thus, it is now possible to take not only national steps but to make political demands at the European level. In his welcoming address, Tomáš Zdechovský, a member of the European Parliament, called for the creation of a common framework to ensure the mental health of refugees.
EU health policy and refugees
Isabel de la Mata from the European Commission began by outlining the European legal conditions that are relevant to a stronger commitment to refugees. According to the treaties, health care is fundamentally a matter for Member States and does not fall within the jurisdiction of the European Union (EU). On the other hand, joint decisions regarding migration is very much a matter of EU jurisdiction. It has hence established a regulatory framework for the provision of health care to refugees.
Within the context of the EU, migrants and refugees are those persons who are not residents of any European state. Thus, EU citizens living in another European Member State are not considered migrants. There are three distinct groups of migrants: The first group includes persons from third countries, i.e. non-EU Member States, that are not affiliated to the EU through agreements such as the European Free Trade Association (EFTA). These persons enjoy the same rights as the citizens of the respective EU Member State, provided that they are legally residing in the EU.
The second group consists of refugees and stateless persons, however only if they have completed a process by which they have been recognised as refugees. These people also have the same claim to health care as the citizens of the given EU Member State; although their freedom of movement can be restricted, such that, for example, a recognised refugee in Munich might not be allowed to access specialised health care available in Berlin. According to EU directives, however, a refugee’s freedom of movement may not be restricted for more than 18 months.
For EU directives to apply in the Member States, they must be transposed into the national laws of those states. In doing so, Member States are not allowed to adopt a stricter regime than is provided for in the EU Directive, but they may adopt one that is more favourable to refugees. According to the relevant EU Directive, a refugee's place of residence may be restricted to his/her accommodations for up to 18 months. A single EU Member State is therefore not permitted to limit the free movement of refugees for as long as 20 months but may reduce the period to only 2 months.
The third group of migrants within the EU are asylum seekers, for whom “essential treatment” must be provided. However, political opinions among EU Member States are highly divergent about what is “essential” for mental health. All Member States have nonetheless adopted the UN Convention on the Rights of the Child, under which all minors in EU countries are entitled to all “necessary services,” irrespective of their status as citizens or refugees. Yet, according to a study expected to be published in July, only four Member States are currently complying with this Convention regulation.
At the European level, there are no common rules concerning people living illegally in a Member State; rather it basically left to each Member State to decide which health care services such people receive. In particular, refugees from African countries arriving in Italy are assessed as economic refugees and therefore have little chance of obtaining regular residency status; and therefore little chance of receiving adequate health care – unlike Syrian war refugees entering the EU via Greece. In many EU countries, health care services provided by non-governmental organisations is not infrequently the only possibility for refugees suffering from a medical or psychotherapeutic illness to receive adequate assistance.
Italy and Greece have been urging other EU Member States to accept more refugees in order that they be distributed equitably, yet this has hardly occurred. This failure, however, is not only due to an unwillingness among the other Member States to accept refugees, but partly also due to the refugees themselves. Many refugees particularly aim to reach countries where they will have opportunities to be integrated into the labour market and therefore turn down opportunities a stay in economically weaker countries, such as Slovenia or Spain.
The political arrangements in the EU concerning refugees are also shaped by the fact that migration and asylum law is primarily written by the interior ministries of the Member States. However, their attitude toward mental illness has been shaped largely by the question of what mental illness is, in the first place. The prevalent mindset is: “You can’t touch it or see it.” This leads to a focus on infectious diseases, while mental illness gets overlooked.
It is therefore absolutely necessary that lobbying efforts regarding mental illness be strengthened at the European level. In Brussels, there are hundreds of organisations lobbying for improvements concerning physical disorders, but only two mental health associations.
Italy (Alberto Zucconi)
Alberto Zucconi is the founder and general secretary of the association of psychotherapeutic schools in Italy. Health services for refugees need to be specifically tailored to them, as in the case of a project underway on Lampedusa. At the European level, psychotherapists need to approach Parliament and the Commission and make clear the importance of further research. With respect to our profession, we should not forget that working with refugees can be difficult and frustrating, and that appropriate training for this work is necessary. He underlines the importance of strengthening the influence of psychotherapists within the EU. In the United States, for example, the American Psychological Association has successfully introduced the subject of mental health into that country’s political consciousness. Psychotherapists should be the first point of contact for questions concerning mental health.
Greece (Christina Popontopoulou)
Christina Popontopoulou works in a Doctors Without Borders rehabilitation facility for torture victims and people who have been subjected to extreme violence. It must not be forgotten that health care is also needed by people who have been staying in Greece for a long time, and that the care they require goes well beyond emergency treatment. A particular problem is the lack of translators for patient care and treatment. This can even lead to doctors being unable to administer emergency medication because they cannot at all communicate with their patients. In this environment, psychotherapy becomes a very remote matter.
Sweden (Aline Braun and Mikaela Lindström)
Aline Braun and Mikaela Lindström work in a centre for the treatment of refugees. The situation in Sweden is good, relative to other countries. In principle, refugees have the same access to health care as Swedes. There are, however, problems in implementing this legal claim. Particularly in sparsely populated areas in the north of Sweden, there are hardly any specialised health services available – although some of the family doctors are doing excellent work. Since treating traumatised refugees is such a specialised area of health care, Sweden’s health care system is not as efficient in practice as the law makes it appear. Collaboration with social services is particularly important.
United Kingdom (Alessandro Storer)
Alessandro Storer works for Mind, an organisation that works for better mental health. In particular, it seeks to make the care provided to mentally ill refugees more inclusive, more accessible and culturally competent. In the United Kingdom, mental health is generally considered a part of overall health. One problem, however, is that the European Union Directive of 2013 does not apply in the UK because of an exemption provision; merely, the former directive applies, which provides for more limited rights, thus making it more difficult to treat mental illness, in particular.
In practice, however, an acceptance of the importance of mental illness is still lacking. Another problem is that many of the specialised treatment centres are in London, but refugees are often accommodated in reception facilities outside the city. There is a translation service in the United Kingdom, which can sometimes even offer cultural mediation competency.
Portugal (Jorge Gravanita)
Across the political spectrum, the overwhelming majority of actors have a positive attitude towards measures that welcome refugees. Portugal is not inexperienced with immigration. In recent history, there have been three major waves of refugees: after the Second World War, after the end of Portuguese colonialism in 1974, and after the fall of the Soviet Union. However, during the recent economic crisis, the public health care sector was subject to considerable cost-cutting measures, which have also affected the care of refugees.
Jorge Gravanita presented the country’s PAR network. Within PAR, the Portuguese refugee council collaborate with professional and scientific organisations and local authorities. This network provides a platform for refugees and is active in Portugal and Greece. It offers emergency assistance in refugee camps, takes a multidisciplinary approach and works with the support of non-governmental organisations and official bodies at the local, national and international level. Since September 15, 2015, about 1,200 refugees have arrived, and about 200 more are expected in the coming weeks. Approximately 1,800 refugees are expected before the programme is completed.
Switzerland (Prof Dr Andreas Maercker)
Andreas Maercker is both German and Swiss, and is a professor of psychopathology and clinical intervention at the University of Zurich. He emphasised the work of the Swiss Red Cross in the provision of care to refugees. He also referred briefly to a peculiarity in Switzerland with respect to professional politics: a fifth of practitioners treating mental illnesses are psychiatrists, while four-fifths are psychologists. Yet, it is the psychiatrists who make the decisions concerning essential questions of financing and organisation. It is therefore important to raise the profile of clinical psychologists at the European level and to represent the psychotherapeutic work of psychologists better.
Poland (Iga Jaraczewska and Anna Derwich)
The stream of refugees from Syria has largely flowed past Poland, as the country is not on the Balkan route. Unlike what is sometimes portrayed in the media, Poland, however, has many refugees, in particular from Russia, Tadzhikistan and the Ukraine. A great many of those from the Ukraine, in particular, are suffering from trauma.
The psychotherapeutic care of refugees in Poland needs improvement and must to be expanded. For example, the country’s only reception centre for refugees accommodates 200 people. Once a week, a single psychologist works there for the day. This is completely inadequate.
Cyprus (Dr Vasilis S. Vasiliou)
The geographical location of Cyprus makes it one of the easiest places for refugees to reach. Cyprus is only 100 kilometres west of Syria and about 60 kilometres south of Turkey. The first large wave of refugees in recent times occurred between 1975 and 1991 with people fleeing Lebanon and Palestine.
On the island of Cyprus there are two centres operated by the asylum and migration services. One is for persons applying for international protection and the other is a temporary centre for those who have been part of mass displacements and who need international protection. In Cyprus, there are no official epidemiological studies or any other studies that have sought to determine the number of mentally ill refugees in the country. There is also no official centre in Cyprus where refugees would receive psychotherapeutic treatment. Once a week, refugees are examined by two psychiatrists and a clinical psychologist, as well as a psychiatric nurse. Mentally ill refugees are referred to the public health system, but there they encounter long waiting lists, due to inadequate numbers of staff who are qualified to provide the specialised care that refugees require.
Germany (Dr Nikolaus Melcop)
Since early 2014, over 1.5 million refugee minors have sought refuge in Germany. Many of them are traumatised, psychologically burdened or ill, and need help. Yet, the health care they are provided with is far too patchy. In particular, the limited provision of health care contained in Germany’s Asylum Seekers Benefits Act and the lack of funding for language mediation dramatically hamper the ability to provide refugees with adequate care. Over the past two years, solutions for helping refugees better have emerged from many initiatives.
In the view of the BPtK, specialised institutions must be allowed to treat refugees as part of the regular provision of care. There should also be no restrictions with respect to the treatment entitlements of refugees. Necessary translation services must be financed and information should be made available to refugees in the relevant languages, so that they may understand it.
Belgium, Hungary, Netherlands, Ireland and Austria
Dr Angelika Kiewel, European Commissioner of the Federal Chamber of Psychotherapists, summarised the reports from five countries that were unable to send a representative. In Belgium , refugees are provided with psychotherapeutic treatment mainly by the Flemish and Walloon Red Cross. In Hungary , the provision of health care to refugees is limited mainly to emergency treatment and basic medical care; psychotherapy is therefore very rarely employed. In the Netherlands , the care of refugees includes psychotherapy and there are also studies on the subject. Ireland has accepted relatively few refugees. Notable is a programme for providing care and counselling to refugees who have begun a course of studies.
In Austria, ten organizations have joined forces in the area of refugee care and, after years of effort, have submitted a joint application for funding to the European Asylum, Migration and Integration Fund (AMIF), in cooperation with the country’s federal interior ministry The AMIF has provided them with a funding commitment until 2019.
Demands concerning the psychotherapeutic care of refugees
Apart from specific matters regarding the provision of care, the participants of the BPtK round-table discussion on refugee policy agreed on the importance of raising awareness about mental illness in the political debate and strengthening acceptance of it as a key priority that must be addressed. They also agreed that the basic, advanced and further education of specialised therapists must be expedited. Cooperative and collaborative arrangements with respect to various areas beyond the actual treatment of refugees must be improved. It is therefore also necessary that specialised advanced or further training arrangements for health care professionals specialising in the treatment of mental illness be put in place. In addition, the long-term financing of ongoing projects must also be facilitated, as many worthwhile projects are financed only for a short period of time.
Another important aspect is cultural competency. In particular, translators need to be specially trained so that their skills include an understanding of the culture of the refugee group and not just its language. The participants also called for the establishment of minimum standards of treatment.
Finally, for their mental illness to be at all treatable, persons suffering from trauma need to find themselves in a safe and secure living environment. This objective would be supported by a welcoming environment within surrounding communities and within society as a whole. The participants therefore advocated for an anti-stigma campaign to influence social attitudes. However, such a campaign would need to run continuously, rather than just selectively. The participants endorsed “stepped care” concepts, whereby, as a first step, refugees are offered information about self-help in a culturally sensitive manner, and the Internet is incorporated into their care.
Greetings Message - Tomáš Zdechovský (MEP)
Greetings Message - Dr Nikolaus Melcop (BPtK)
- Alberto Zucconi, Italy
- Christina Popontopoulou, Greece
- Aline Braun and Mikaela Lindström, Sweden
- Alessandro Storer, United Kingdom
- Jorge Gravanita, Portugal
- IIga Jaraczewska and Anna Derwich, Poland
- Dr Vasilis S. Vasiliou, Cyprus
- Sonja Kinigadner, Austria
- Belgium, Hungary, Netherlands, Ireland
Psychotherapeutic care for refugees
Appropriate psychotherapeutic care for refugees is an important concern. To get an overview of how other EU member states are dealing with the topic and how psychotherapeutic care of refugees is organised there, the Federal Chamber of Psychotherapists in Germany (BPtK) conducted a survey based on a structured questionnaire of the members of the Network for Psychotherapeutic Care in Europe (NPCE) and other organisations and experts in this field of work in the second half of 2016. At this round-table, the results of the survey will be presented and discussed with the participating international experts.
The specialist event will also be associated with an NPCE member meeting, at which perspectives and priorities for future work will be defined. This is to be open to interested new members of the network from the sphere of psychotherapeutic experts.
22 and 23 March 2017
Round-table discussion: Psychotherapeutic care for refugees
Office of the Federal Chamber of Psychotherapists in Germany
Agenda: Round Table Discussion - Psychotherapeutic Care For Refugees
Written Declaration on the mental health of asylum seekers
There is too little attention for the mental health risks faced by refugees and asylum seekers and their insufficient access to psychotherapeutic services in the welcoming countries. Policymakers across the EU should be more aware of the fact that this is a real and serious issue.
The NPCE sustains the Written Declaration on the mental health of asylum seekers emerging from the initiative of the Members of the Interest Group on Mental Health, Well-being and Brain Disorders of the European Parliament. It calls upon the Council and the Commission to take account of the mental health needs of asylum seekers and to show compassion for their plight when implementing their respective competences under the Treaties.
The Declaration (0082/2016) needs the votes of half of the Members of Parliament to become a formal Parliamentary document. Until 12 December the signatures of 376 Members of Parliament are needed to have the Declaration adopted. Please write to the Members of the European Parliament from your countries to call on them to sign the Declaration. You will find the Written Declaration in English here. We can provide you with the text of the declaration in your native language, the emails addresses of the Members of Parliament from your countries and the form MEPs need to sign.
Please contact: firstname.lastname@example.org
Written Declaration on the mental health of asylum seekers
Survey of the Network for Psychotherapeutic Care in Europe about the psychotherapeutic care of refugees in the EU
In 2015 estimated 19.6 million refugees worldwide have lost their homes to escape war and persecution —half of them being children. In Germany for example more than 1 million people have sought protection last year. Besides physical illness refugees suffer from acute mental health problems and trauma symptoms, above all post-traumatic stress disorder and depression.
The inadequate provision of care to refugees is an international topic of concern. Most countries offer some basic health care facilities, but mental disorders often are only treated in exceptional cases. Until now there is little evidence how the matter is being addressed in the different countries The Federal German Chamber of Psychotherapy (BPtK), in cooperation with the NPCE, therefore carries out mopping the situation of mental health care for refugees in the welcoming European countries. In case you are an expert in this field, please join the survey.
You will find the questionnaire here, for more more information on Health care for refugees in Germany please follow this link.
Please send your completed questionnaire to the following eMail-Address: email@example.com
Download: Survey about the psychotherapeutic care of refugees in the EU
NPCE contributes to EU Commission consultation on access to health services
The NPCE sent a general comment to the European Commission's public consultation on the preliminary opinion on ‘Access to health services in the European Union’. Despite the fact, that mental illnesses are treatable and the best treatments today are highly effective, there are serious gaps in the provision of services. The contribution underlines the following objectives:
- Promote health as quality factor of life and social value.
- Give priority in investment in prevention and early intervention and create specific programs dedicated to vulnerable populations.
- With the impoverishment, unemployment, isolation due to immigration, more human resources for the medical and psychosocial care for families and individuals is needed.
- Adapt health services to people and communities, effective decentralization of services, bringing services closer to communities.
- Networking with professionals, local and communities associations.
- The whole mental health professional staff needs a common ground of positive therapeutic attitudes and ethics. Building shared attitudes should be part of multi-professional efforts in developing quality standards in health care and multi-professional engagement in mental health care management.
- There is a need for first line treatment prior to medication that follows best practice and is driven by evidence.
- Mental health care should be taken as a priority, for that clinic psychology and psychotherapy services (for adequate prevention and intervention) should be included as first-line response in basic health services, with preventive value for the diagnosis and psychological treatment in this area.
PUBLIC CONSULTATION ON THE PRELIMINARY OPINION ON ‘ACCESS TO HEALTH SERVICES IN THE EUROPEAN UNION’
Conference report: European Health Forum Gastein 2015 - Securing Health in Europe
The 18th European Health Forum (EHFG) was held from 30 September to 2 October, 2015, in Gastein, Austria, and was titled “Securing healthcare and sustainability, strengthening healthcare systems.” Nikolaus Melcop took part on behalf of the Federal Chamber of Psychotherapists (BPtK) and the Network for Psychotherapeutic Care in Europe (NPCE).
In the course of the event, Mr Melcop had the opportunity to speak personally with Vytenis Andriukaitis, EU Commissioner for Health and Food Safety, and explain the need for improving psychotherapeutic care across Europe. In addition to addressing the overall supply shortage of such care that already exists, the European states must in particular establish psychotherapeutic services for the high numbers of mentally ill refugees arriving in Europe. Commissioner Andriukaitis affirmed this assessment and emphasized the important role of psychotherapeutic care in these circumstances. He assured Mr Melcop that these problems would be addressed by the EU Commission, and that efforts for improvement would be supported.
The entire conference was shadowed by the sharp increase in refugees arriving in Europe. Prof. Helmut Brand, President of the EHFG, stressed that the situation is particularly about European healthcare systems being additionally burdened by the ongoing influx of asylum-seekers. Prof. Brand summed up the discussion: “It’s a matter of primary medical care in the short term, caring for post-traumatic disorders – particularly among children – in the medium term, and adapting our healthcare systems to increasing migration in the long term.” Many presenters emphasised the European vision founded on solidarity and shared values. The principle of equal access was asserted as a primary objective. New technologies, in particular e-health practices, were identified as ways to facilitate this, and to work efficiently with resources.
Models and ideas for improving the provision of healthcare were proposed, such as a future scenario in which each individual would manage his or her own health, thus assigning the responsibility of ownership, control and disclosure of personal health information to the individuals themselves. During the forum, the European Health Award ceremony was also held. This year’s winner was the MiMi Project (Healthcare with Migrants for Migrants).
For further information, please read the correponding EHFG Press Releases
At least half of refugees are suffering from mental illness
“Mental Disorders among Refugees”: The position of Germany’s Federal Chamber of Psychotherapists (BPtK)
At least half of refugees in Germany are mentally ill. Most are suffering from post-traumatic stress disorder (40 to 50 percent) or depression (50 percent). These two diseases frequently occur simultaneously. Refugees who suffer from post-traumatic stress disorder (PTSD) are often suicidal. Forty percent of them have either previously planned to take their own life or have attempted to do so. Mental disorders caused by traumatic experiences are also particularly common among child refugees in Germany. In fact, one in five child refugees is suffering from PTSD, a rate that is fifteen times higher than that for children born in Germany. These are the central points contained in "Mental Disorders among Refugees,” a position paper presented today by the Federal Chamber of Psychotherapists (BPtK).
Psychotherapy is the recommended method of treating PTSD. Solely treating this disorder with medication is not sufficient, and generally not medically responsible. Yet, only about four percent of mentally ill refugees receive psychotherapy. “Mental disorders are among the most common illnesses among refugees. As a rule, they urgently require treatment,” insists Dr Dietrich Munz, President of the BPtK. “The arriving refugees not only need accommodation and food, but also medical care. However, almost no mentally ill refugees are receiving appropriate care. The BPtK therefore urges that legislative changes be made, and that authorities be granted to psychotherapists and refugee centres, to enable guideline-appropriate treatment to be received by mentally ill refugees.”
Escape and trauma
Events that are life-threatening and catastrophic for those who experience them, and which cause deep despair, can lead to severe mental illness. PTSD most frequently occurs following traumatic events perpetrated by other people – by so-called “man-made disasters.” Approximately half of the victims of rape, war, forced migration and torture suffer from PTSD. Among the most common “man-made disasters” reported by refugees are being under attack with firearms and grenades, hunger and thirst (e.g. during imprisonment), death threats and mock executions, physical torture, electric shocks, sexual humiliation and rape, and witnessing executions and incidents of rape.
Those suffering from PTSD live through the traumatic event(s) repeatedly, usually in the form of nightmares or flashbacks. These recollections are experienced with such intensity that the sufferer feels as though the events are actually re-occurring. During their flight to Germany, Yezidi women who escaped captivity in the Islamic State experienced flashbacks and panic attacks that included palpitations, shortness of breath, dizziness and fear of death. The close confines of the airplane triggered memories of their captivity. PTSD sufferers therefore avoid situations that can evoke memories of their traumatic experiences. Other symptoms of PTSD are pronounced jumpiness, sleep- and concentration-related disorders, emotional numbness and indifference toward other people. “PTSD sufferers are severely mentally ill,” explains Dr Munz. “They urgently require psychotherapy. It is shameful that people with such severe and painful psychological wounds almost never receive appropriate assistance.”
In accordance with the current EU directive regarding the reception of vulnerable persons, Germany is obliged to take into account the specific circumstances of such individuals. Such vulnerable persons are defined as those with mental illnesses and those who have been subjected to torture, rape or other serious forms of psychological, physical or sexual violence. This directive was supposed to have been implemented by July of this year. In fact, the provision of care to mentally ill refugees in Germany remains shamefully poor. Indeed, the amendments made to the Asylum Seekers Benefits Law (Asylbewerberleistungsgesetz) in March 2015 brought no improvements for mentally ill refugees. The BPtK therefore urges that the treatment of mentally ill refugees be improved. This will in particular require social service agencies to have qualified assessors in place, refugee centres and private psychotherapy practices to be empowered to treat afflicted refugees, and funding for translation/interpreting services.
Benefits under the Asylum Seekers Benefits Law
The decision by social services as to whether psychotherapeutic treatment is to be provided to a mentally ill asylum seeker during the first 15 months of his/her stay in Germany often takes several months. Most often, the decision as to whether psychotherapy is necessary or not is made by case workers or physicians whose training with respect to mental illness is either non-existent or inadequate. This often leads to erroneous assessments. Mental illnesses are thereby wrongly judged not to require urgent treatment, or are judged only to require a drug treatment, which is in fact inadequate. “The assessment and granting of psychotherapeutic treatment provided by the Asylum Seekers Benefits Law is grossly deficient,” explains Dr Munz. “In future, all applications for psychotherapy should only be reviewed by qualified assessors.” In the view of the BPtK, it is also unacceptable that refugees in Germany are being deprived of medical treatments that are considered in Germany to be necessary medical care. The restrictions on medical care to refugees stipulated in the Asylum Seekers Benefits Law should therefore be repealed.
Empowerment of refugee centres and private practices
After a stay of 15 months in Germany, refugees are entitled to statutory health insurance benefits. In principle, those refugees suffering from mental illnesses are then finally entitled to psychotherapy. Those currently receiving such psychotherapy are almost exclusively being treated in psychosocial centres for refugees and victims of torture. However, most of the psychotherapists who work in such centres are not entitled to bill the public health insurance authority. This means that after the 15-month period, refugees are also left receiving practically no psychotherapeutic treatment. The BPtK therefore calls for the entitlement of psychotherapists in refugee centres, as well as private psychotherapy practices, to bill the public health insurance authority for the treatment of refugees. This would be possible, based on the authorisation regulation applicable to physicians. “This would significantly improve the treatment of mentally ill refugees in a rapid and un-bureaucratic manner,” explains Dr Munz, President of the BPtK.
The psychotherapeutic treatment of refugees nearly always requires the assistance of interpreters. To date, the costs of interpreting services are seldom covered by social services, and never by the public health insurance authority. The BPtK therefore proposes that the Asylum Seekers Benefits Law be amended to entitle all refugees to interpreting services, when such services are necessary for their medical treatment.
Press Release "At least half of refugees are suffering from mental illness - Mental Disorders among Refugees: The position of Germany’s Federal Chamber of Psychotherapists (BPtK)"
(German Language Version, BPtK-Homepage)
EU Parliament breakfast discusses on “Standardisation of Heathcare Services and Patient Safety”
On 27th of May 2015 the Federal Chamber of Psychotherapists, together with the German Medical Association and the German Dental Association organized a breakfast debate in the EU-Parliament on Standardisation of Healthcare Services and Patient Safety. The breakfast debate was hosted by MEP Dr. Angelika Niebler (German, EPP) and MEP Dr. Andreas Schwab (German, EPP). About 25 representatives from the EU-Parliament, the EU-Commission, Regional German State Ministries, German health provider organizations, including hospitals, from The Standing Committee of European Doctors and the European Social Insurance Platform attended the discussion.
The speakers expressed their concerns on current activities of the European Committee for Standardisation (CEN) in the development of standards for healthcare services. They agreed:This activities are superfluous, inexpedient, intervene in national competences and raise serious concerns with regard to legitimacy and the preparation process. The standardisation of health professional services lacks market relevance and added value. At the conclusion of presentations, a lively discussion took place on the need, to develop standing principles for health care in a transparent process by independent medical and therapeutic experts. Standards from the CEN as a profit organization should refer on technical standards for products and should not be extended on public services and health care.
CEN is currently developing standards e.g. in the field of cosmetic surgery, treatment of cleft lips, homeopathy and osteopathy, dealing with requirements of documentation, qualification and for facilities. These activities are initiated by national members within the CEN. The EU Commission is empowered by regulation to initiate standardization processes, including public services and health care.
The hosting Members of Parliament of the event, Dr. Angelika Niebler and Dr. Andreas Schwab, announced to engage for a position of the Parliament that health care services should be taken out of the Commission’s activities in the field of standardisation.
Programme Parliamentary Breakfast 27 May 2015
Dr Nikolaus Melcop (BPtK) on “Standardisation Of Therapeutic Services Using The Example Of Psychotherapy”, Text Of Speech
GVG EU Committee, Position of “Standardisation Of Healthcare Services”
2nd International Conference of the Polish Society for Psychotherapy Integration
From 6-8. June 2014 is taking place the 2nd International Conference of the Polish Society for Psychotherapy Integration-“Integration in Psychotherapy-Effectiveness and Limits” in Warszawa, Poland. It offers lectures and workshops with Prof. Leslie Greenberg, Prof. Stanley Messer, Prof. George Silberschatz, Dr Martha Stark, and Dr Kenneth Frank. The event will also be great opportunity to meet colleagues from all over Europe.
PSIP conference program EN 140315.pdf
Improved Access and Enhanced Collaboration
Conference: De-medicalising primary mental health care
On 30th & 31st May 2013 about 180 professionals across many disciplines – psychologists, psychotherapists, general practitioners, primary mental health care workers, researchers, policy makers and stakeholders - met at the University of Limerick/Ireland to discuss the political, social and scientific challenges to improving public access to talk therapies. The event was hosted by Member of Parliament Nessa Childers (Socialists & Democrats), and organized in partnership with the Network for Psychotherapeutic Care in Europe (NPCE).
Key speakers from Ireland, Europe and the US presented papers examining the political, social and scientific challenges of mental illness and addressing ways and means of providing improved primary mental health care that offers talk therapy rather than the medical approach that currently predominates. In her opening speech Nessa Childers emphasised that “apart from the obvious benefits for individuals, good mental health is increasingly important for economic growth and social development in Europe. All these are key EU policy goals”.
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Nessa Childer, MEP
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Dr Declan Aherne, University of Limerick
“Talk therapies are the most suitable form of treatment for the majority of mental health issues and could be made available at primary care level at no extra cost. In Ireland 90 percent of people with depression are currently receiving medication while the recommended treatment for depression in 70 per cent of cases is psychotherapy only. The total annual cost of psychological services at primary care level would be almost 20% less compared with the amount spent on antidepressant drugs in community drug schemes in 2012”. This was the key message from Dr Declan Aherne, clinical psychologist, head of counseling at the University of Limerick and one of the core members of NPCE.
Fiona Ward, director at the HSE Dublin North East, also acknowledged that there had been a 25 per cent increase in prescriptions for anti-depressants and other psychiatric drugs in the past five years for medical cardholders. “Providing counseling and therapy at primary care level can reduce stigma, offer early intervention, reduce the number of GP visits and prevent more complex difficulties,” said Ms Ward.
Examples of good practice from other European countries were presented. They showed that all European health care systems face the same challenges for the future and that there is the possibility and the need to improve services in every country. “Conditions for the work of psychotherapists in Germany are well developed, patients’ direct access to a psychotherapist is assured and psychotherapy is well integrated into the medical health care system”, reported Prof. Rainer Richter, President of the German Chamber of Psychotherapists and initiator of the NPCE. “Psychotherapists are highly qualified, but not enough use is made of psychotherapy's potential. The structures of the healthcare system lack coordination and cooperation in the care of mentally ill people.
Financial resources are not allocated efficiently. General practitioners and psychotherapists must work together more closely. The GPs have to be trained to recognize the need for psychological treatment. For patients with complex treatment needs in particular it is necessary to set up a horizontally and vertically integrated system of care”, he explained.
Prof Rainer Richter, President BPtK
The conference also heard about free access to short-term psychotherapy for all citizens at primary care level in Holland. “We work close to the living environment of the patient in close connection with the doctor and social worker and we see patients in the practice and at home,” explained Prof Jan Derksen from the department of clinical psychology at the University of Nijmegen. “We ask the GPs not to start prescribing medication before we see the patients and we have new plans for GPs and psychotherapists to treat patients in shared consultation,” he said. The need for mental health services to reach out to people in areas with high levels of social deprivation and the need for first line treatment prior to medication was the focus of a talk by Dr Jim White, clinical psychologist who leads the primary care mental health team in southeast Glasgow.“We are dealing with people who are demoralized, demotivated and not psychologically minded so we shouldn’t have waiting lists and hurdles for them to cross to get to therapy,” said Dr White. He stressed the importance of leaving the clinic and meeting people where they are.
Patrizia Reilly, cabinet member in the office of the European Commissioner for Research and Innovation pointed out the chances within the EU's new funding programme for research and innovation Horizon 2020 that is currently being discussed. “Health and wellbeing for all will be one of the cornerstones of Horizon 2020, which will begin in 2014. Such an encompassing programme fits the cross-disciplinary nature of mental health research that you are discussing today” she underlined.
In effect, participants agreed on the need to move away from the medical model that is currently in place and towards a psychosocial model that follows best practice and is driven by evidence. They underlined the idea of creating a system that integrates mental health into different services. It was put forward that pathways are not always sufficient clear. In order to make collaboration accountable, it also becomes important to understand how the different orientations within psychotherapy work and to develop in the direction of a unified theory.
Participants emphasized the need to pilot a project by the European Commission on improving access to psychotherapy across a number of European states and underlined the will to achieve enhanced collaboration across professional groupings in the future.
Conference Presentation Nessa Childers, MEP
Conference Presentation Dr Declan Aherne, University of Limerick
Conference Presentation Prof Rainer Richter, President BPtK
A third European Conference on Psychotherapy will take place under the headline
De-medicalising primary mental health care: Can we afford to, can we afford not to?
Revolutionising access to psychological care in Europe
Hosted by Nessa Childers MEP
In association with the Network for Psychotherapeutic Care in Europe (NPCE)
University of Limerick 30 & 31 May 2013
Examining the political, social and scientific challenges to improved public access, through primary care, to psychotherapy across the EU - key speakers from Ireland, Europe and the US will present papers addressing different aspects of primary mental health care. This conference is aimed at increasing our knowledge and understanding of the issues facing primary mental health care and of identifying ways and means of facing these challenges.
Being held on the occasion of Ireland’s Presidency of the Council of the European Union, a main objective is to generate a proposal to the European Commission to pilot a project on improving access to psychotherapy across a number of European states. A further aim is to achieve collaboration across professional groupings in this endeavour.
Who should attend
This conference is for professionals across all disciplines – clinical psychologists, psychotherapists, counsellors, general practitioners, primary mental health care workers etc. – as well as researchers, policy makers and all stakeholders who have an interest in and are working in primary mental health care or would wish to do so.
Participants will gain a clear insight into the contribution of talk therapies to primary mental health care as well as an understanding of how non-medical primary mental health services can be delivered efficiently and effectively.
You can view the entire conference programme here
Please view speakers' biographies here
EXPERT PANEL SPEAKERS
Names of our expert panellists can be viewed here
The conference is being held over two days, and registration is essential. Delegates can register for either day, or register to attend both days. Registration is €25 per day. This includes lunch and refreshments during the conference.
Delegates may also wish to attend the Gala Dinner, cost €45, being held in the University on Thursday evening, 30th May, pre booking is also essential for this event.
To book your place please register here online registration form
For more information on the conference
Phone: Bronwen Maher 087-7841937 (toll free)
The Portuguese Society of Clinical Psychology has organized a III International Forum on Clinical Psychology.The conference took place in Lisbon on April 11th, 12th, 13th. under the headline
Challenges of Contemporaneity in Europe Psychotherapeutic Perspectives on Mental Health-Care and Well-being
Download Conference Report here