By Veronica Defièbre, member of the board and vice president of the “Assoziation Schweizer Psychotherapeutinnen und Psychotherapeuten” ASP
During the first lock down during the COVID-19 pandemic the Swiss Departement for Health (BAG) which is part of the Federal Departement of Internal Affairs (EDI) of which one of the Swiss Federal Council members Alain Berset is the head of, was certainly confronted with a quite new and challenging task. They had a lot to cope with and we understood that the situation of the psychiatrists and psychological psychotherapists was not their first concern, but it isn’t handled satisfactory until now.
Firstly, I would like to bring to your attention the situation of psychological psychotherapists in Switzerland: They can reimburse the costs of their psychotherapies only by the general health insurance if they work together with a psychiatrist in the so called delegating system. The psychiatrist is responsible for everything the psychotherapist does in his or her psychotherapy, but the exact way how they are working together, apart from having to work in the same practice, is not clearly regulated. Therefore, there is a lot of misuse, for example psychiatrist, who charge their delegated psychotherapist up to 80% of his or her income as part of the delegation contract.
Apart from this system the psychological psychotherapists can work in their own practice and reimburse their psychotherapy costs via the private health insurance or the patients can pay themselves. This kind of psychotherapy isn’t regulated that strictly as the delegated one. Delegated psychotherapists for instance are not allowed to perform psychotherapy online and the sessions via phone are limited to 240 minutes per 6 months.
In the following I’m only referring to the psychological psychotherapists who are working in the delegating system and who are very important especially for patients with low income who cannot afford a private health insurance or pay for their psychotherapy by themselves.
In the beginning of the first lockdown the psychological psychotherapists had the same regulations as the psychiatrists. They were allowed to perform online-sessions with their patients or talk to them on the phone and could charge it as a face-to-face session. But after a few weeks of this practice the BAG returned to the usual regulations, that psychological psychotherapists are limited to 240 minutes per 6 month for psychotherapy on the phone, but also permitted online therapy via a video conference system, which was prohibited before. The psychiatrists were still allowed to continue the practice of charging phone and video calls as face-to-face sessions and were thus free either to see their patients in the practice or do it online or via phone. The psychotherapist associations such as the ASP intervened and required even together with the associations of the psychiatrists that psychological psychotherapists should be unlimited as well, because they otherwise could either be in contact with their patients rather rarely or the patients would be forced to go to the practices and endanger themselves and the psychotherapists of being infected by the corona virus. The reaction was that the BAG raised the permitted 240 minutes of psychotherapy via phone up to 360 minutes per 3 months for psychological psychotherapists. This was extended until 1st of July 2021 and has just finished this month. In spite of all protest of the associations the BAG is not prepared to change the law and permit online therapy even though the COVID-19 pandemic is still going on.
The only other effort that was made was a hotline the BAG planned to install in the beginning of the pandemic. The psychotherapy associations supported the BAG and organized psychotherapists who would be working on this hotline, but in the end the BAG gave up this project due to difficulties they had technically.
But apart from these frustrating aspects the psychotherapy associations have achieved an important goal: The Swiss Federal Council has agreed to abolish the delegation system which will be replaced by the so called “Anordnungsprinzip” which is still not ideal but certainly an improvement. We are still negotiating with the EDI and Alain Berset the exact terms of it. It ist planned, that all general practitioners and psychiatrists will be able to order 15 hours of psychotherapy sessions. After 15 hours the ordering doctor has to receive a report of the psychotherapist in case the patient wishes to continue the psychotherapy. After another 15 hours a psychiatrist has to decide if more sessions are necessary and, in case he should agree, the doctor has to write a report for the health insurance. Neither the psychotherapist associations nor the associations of the psychiatrists support this involvement of the psychiatrists. It makes the whole process unnecessarily complicated. The associations think the BAG is still trying to limit the independence of the psychotherapists and have them under the control of doctors because they don’t trust them to be competent enough. The fact that the doctors have to write the report and not the psychotherapists has in our opinion the same reasons. In the daily practice the psychotherapists will do it as they already are doing it in the delegating system: They will write the reports in the names of others, even though in the present system it should be the psychiatrists who are writing the reports for the health insurances, which takes away the responsibility from the psychotherapists. Certainly, another important aspect of and reason for these restrictions are the health costs which the EDI wishes to limit as much as possible. We are trying to change these terms of the “Anordnungsprinzip” and hope that we will succeed, but don’t know yet. Apart from that the change in general is welcome as the psychotherapists are able to work in their own practices and are no longer obliged to work so closely together with psychiatrists. We think that this change was made possible because of the COVID-19 pandemic. It has shown how important psychotherapy is in such a crisis and how even more important is an easy access to it.
The new system will start on the 1st of July 2022.
- Population 7.8 million; expenditure on health is 10.8% of the GDP
Expenditure on health in Switzerland in 2007
|Costs of the health care system|| 10.8% of gross domestic product (GDP)|
| Health costs per inhabitant|| EUR 5’530|
| Costs of the health care system|| EUR 42’159 million|
| - therefrom outpatient care|| EUR 13‘261 million|
| - therefrom inpatient care|| EUR 19‘179 million|
| - others|| EUR 9‘719 million|
| Portion of (compulsory) social basic insurance|| 35% of health care expenditure|
| || |
| Expenditure on Psychiatry & Psychotherapy* (inpatient care)|
(Only psychiatric hospitals and psychiatric clinics. Psychiatric and psychotherapeutic treatments in general hospitals not included!)
| EUR 1‘412 million|
| Expenditure on Psychiatry & Psychotherapy* (outpatient care)|
Of that, expenditure on physician-delegated psychotherapy conducted by psychologists
| EUR 384.75 million (0.91% of health care expenditure)|
EUR 87.6 million (0.21% of health care expenditure)
| Costs in EUR of outpatient and inpatient psychotherapy|| No breakdown statistics available|
*In Switzerland, physicians (medical doctors) specialising in Psychiatry & Psychotherapy, as the double title indicates, work in both psychiatry and psychotherapy. There is no breakdown of the costs available for psychotherapy alone.
Psychotherapy in the health care system
- Types of psychotherapeutic treatments available
- Indication: Preconditions (e.g. prior authorisation, prior treatments)
- Quality management requirements (guidelines, outcome evaluation)
- The psychotherapeutic treatment of mental illnesses is in principle not limited to certain methods or tied to certain techniques. The 3-4 main approaches are: behavioural therapy, analytic psychotherapy, systemic psychotherapy, person-centred therapy. In Switzerland, many variants of these approaches have become established.
- With the soon-to-be-adopted Psychologieberufegesetz [Law on Professions in Psychology] and the obligatory federal accreditation of psychotherapy training programs, the main psychotherapeutic approaches are likely to gain in importance. For diagnosis the ICD-10 is usually used.
- Patients’ access (e.g. direct access, access via a general practitioner or specialists)
- Outpatient therapies and treatments by physicians (medical doctors) specialising in Psychiatry & Psychotherapy are financed by the social health insurance (up to 40 hours per year). In medical care, the services are not broken down separately for psychiatric and psychotherapeutic services.
- Psychotherapy conducted by psychologists is paid for by the social health insurance only if the psychologist is employed by a physician and the physician bears formal responsibility for the therapy. In the outpatient area, a breakdown of costs is available only for this “physician-delegated psychotherapy conducted by psychologists”.
- Primary care physicians usually refer patients with psychological problems to a medical specialist, a psychologist conducting physician-delegated psychotherapy, or a psychologist in independent practice providing psychotherapy. In the last case, however, the social insurance does not pay for the therapy, and patients only receive a partial reimbursement if they have private additional insurance.
- Referrals for inpatient treatment are usually made by medical specialists in Psychiatry & Psychotherapy but are also made by psychological psychotherapists in cooperation with medical doctors.
- Professions, qualifications prior to specialisation and postgraduate training in psychotherapy, accepted psychotherapeutic schools/approaches
- Requirements for providing services within the health care system
- Additional services (prescriptions, assignments)
- The independent conduct of psychotherapy is regulated by law in 25 of the 26 cantons of Switzerland. As a rule, psychotherapists study psychology or medicine as undergraduates; they then complete postgraduate training in psychotherapy (minimum 4-5 years). Already in 2001, 85% of psychotherapists that were not medical doctors had undergraduate degrees in psychology. At present, a federal law on professions in psychology is before the Swiss parliament: By this future national law, only psychologists or medical doctors can be trained and licensed in psychotherapy.
Psychotherapy for Depression
- Special concepts (apart from 3.)
- Best practice models
- Because depression has reached epidemic proportions, up to now eight cantons of Switzerland have launched a cantonal “Alliance Against Depression” (like the Nuremberg Alliance Against Depression). Four cantons are following a longer-term strategy in the area of mental health. As a coordinator, the federal government supports the cantons in establishing the Alliance Against Depression. However, the federal government itself has no authority to act in the area of mental illnesses. A new law on this is currently under parliamentary consultation (“federal law on health prevention and promotion”).
Desirable Changes to Health Policy
- If you were responsible for health policy in your country, what would your first decision be regarding psychotherapeutic care?
- 1. There should be a lower threshold for psychotherapy service provision, and at the same time mental illnesses (and thus also psychiatry and psychotherapy) must become destigmatised.
- 2. Access to psychotherapy should be improved, by better integrating psychologist psychotherapists into the social basic insurance.
- 3. Promotion of mental health must be improved altogether, and that includes prevention of mental illnesses.
Daniel Habegger, Federation of Swiss Psychologists FSP www.psychologie.ch
The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".
You can download the paper here.