The concept of Psychosomatic Care in Germany
a model for other countries?
19th ICPM - Québec August 2007
Structured psychosomatic care
The revision of the post-graduate training regulations at the German Medical Assembly 2003 (“Deutscher Ärztetag 2003”) has also given rise to the development of a new, internationally unique care concept in psychosomatic medicine, which has attracted the interest of other European countries.
This psychosomatic and psychotherapeutic care concept has matured over a period of some decades and now presents itself in a co-ordinated, tripartite form:
Basic psychosomatic care
The provision of primary psychosomatic care is founded on a basic psychosomatic qualification which enables the physician, primarily the general practitioner, to recognise psycho-social aspects of the patient’s clinical picture at first contact, to evaluate the significance of these aspects for further medical care and, if necessary, to select a route for special psychosomatic and psychotherapeutic treatment. Thus primary psychosomatic care is accorded an important screening function for the further treatment processes.
Since 2003, this qualification has formed part of the required training for general practitioners and gynaecologists.
In somatic specialist areas, further education and training in subject-related psychotherapy is intended to qualify the specialist in his/her field (for example, gynaecology; urology) to provide care for his/her patients, on the basis of an established relationship of trust, with the limited involvement of psychosomatic aspects, providing there is no indication of a need for referral to a specialist in psychosomatic medicine and psychotherapy or where it is clear that the patient would not tolerate such a referral for psychological reasons.
The specialist in psychosomatic medicine and psychotherapy represents this subject in its entirety, at the same level as the other medical specialists in their fields, at the comprehensive levels of further psychosomatic and psychotherapeutic education and training required. The specialist is responsible for the “recognition, psychotherapeutic treatment, prevention and rehabilitation of states of suffering and illnesses caused by psycho-social and psychosomatic factors including somatic and psychic interactions.” (Definition of the subject as stated in the model post-graduate training regulations of the German Association of Physicians (“Bundesärztekammer”). In addition to psychological and psychotherapeutic treatments, this specialist also applies medical and pharmacological treatment methods, plans structured, multi-modal and multi-methodological, psychosomatic-psychotherapeutic treatments in the out-patient and (to some extent) in-patient sectors and makes use of the necessary and available medical treatment options or calls in other medical specialists or psychotherapists.
The psychosomatic specialist also participates considerably in further education and training in basic psychosomatic care and subject-related psychotherapy and, with these qualifications, retains access to the methods of guideline psychotherapy.This concept recognises that the early consideration of psychosomatic coherences in diagnosis and therapy can prevent chronicity and thus also limit the economic consequences.
The self-image of physicians in psychosomatic medicine
The specialist in psychosomatic medicine and the physician who is active in psychotherapy harmonise their identities as physicians, which have been established through their medical studies, with the additional psychological and psychotherapeutic characteristics acquired through further education and training in psychosomatic medicine.
The psychosomatic specialist is first and foremost a physician and therefore orientates himself towards the typical medical question: “what would help this patient?” and not towards the question: “can I apply my method?” This is a patient-centered approach.
The physician who has trained in psychosomatic medicine takes, as a point of reference, the thought systems of the natural sciences, with an extended concept of nature – whereby nature is not just “external” (body) but also “internal” (psyche) – and psychology as a science of man’s psychological nature and social behaviour.Thinking in psychosomatic coherences and a medical psycho-therapeutic dual competence are complementary aspects of the psychosomatic specialist’s professional self-image.
Concept and prospects
In 2005, a specific psychosomatic chapter was introduced and established for the first time within the uniform relative value system of fees for SHI services (“Social Health Insurance”)
Thus, in theory, the provision of method-bound guideline psychotherapeutic care could be supplemented by the described and required, low-threshold, flexible, patient-centred, specialised psychosomatic care, which is an essential consideration because this area of medicine cannot be adequately covered by guideline psychotherapy alone.Remark: As some of you know, so-called guideline psychotherapy (including psychoanalysis, psychodynamic psychotherapy and behavioural therapy) has been included in the Social Health Insurance system in Germany since 1978.
New opportunities have arisen as a result of these developments but a few problems still remain:
In contrast to guideline psychotherapy, which is at present still sufficiently well-financed and also supported by specialists, the new psychosomatic specialist chapter is not yet economically viable, so that the indicated resources cannot yet be used effectively for patient care. There is clearly a need to intensify our efforts in the political field. We are, however, working hard to find successful solutions.
Nevertheless, it should be remembered that, four decades ago, the German medical system had already developed a highly qualified, comprehensive psychotherapeutic care structure to provide the population with health care within the framework of the Public Health System. In comparison with international standards, this structure is exemplary and still unsurpassed. (Guideline psychotherapy).
Policy-makers would do well to adopt, promote and utilise the new specialist psychosomatic care structures which have been developed by the medical professionOutside Germany, at present, psychosomatic medicine and psychotherapy are only found as a separate medical specialty in Latvia. In Japan, physicians can specialise in psychosomatic medicine and internal medicine and in a few countries – including Canada – psychosomatic medicine exists as a medical sub-specialty. Austria will probably be the next country to introduce psychosomatic medicine as a sub-specialist qualification (Zweitfacharzt ). In Warsaw, in January 2007, the European Network of Psychosomatic Medicine (ENPM) was founded as a forum for the discussion of international developments in this field. The impetus for this came from an ECPR symposium held in Croatia in 2006.
The primary aim of this European Network is to develop minimum education standards for practitioners working in the field of psychosomatic medicine. The structured psychosomatic care system in Germany could serve as a framework for the further development of psychosomatic care systems in other countries.
Association of Specialists
in Psychosomatic Medicine and Psychotherapy of Germany
Dr med. Herbert Menzel
Specialist in Psychosomatic Medicine and Psychotherapy
Specialist in Psychiatry and Neurology
- Psychoanalysis -
Chairman of Association of Specialists
in Psychosomatic Medicine and Psychotherapy of Germany
Homepage: http://www.bpm-ev.de/
Email: Doktor.h.menzel@t-online.de
Specialist in Psychosomatic Medicine and Psychotherapy
Specialist in Psychiatry and Neurology
- Psychoanalysis -
Vice-Chairman of BPM e.V.