Cognitive Behavior Therapy in Germany
Heiner Vogel & Julia Zdrahal-Urbanek
University of Würzburg, Institute for Psychotherapy and Medical Psychology
Behavior therapy was “imported” to Germany by several dedicated German
psychologists1 in the late 1960s. The orientation towards the new therapeutical method
was soon spread over university chairs and clinical psychology sections and became
here the dominating psychotherapy in the late 1970s. The advantages of the
implementation of behavior therapy into public health services were soon apparent, and
the new method became officially authorized to be applied within out-patient health
services in the 1980s.
It is of great importance to stress that a differentiation between behavior therapy
and cognitive behavior therapy is nowadays not relevant within institutions in which
psychotherapy is applied and concerning political and structural development. When
German authors adopted cognitive therapy and cognitive behavior therapy, a “cognitive
change” took place under behavior therapists in the 1970s (an “emotional change” could
be reported later, as well), and therapeutic actions started to focus more and more on
cognitions. It was and is still occasionally criticized, though, that this development can
also be seen as an immunization strategy as “controlled” therapy is combined with
difficulties due to the fact that cognitions are not observable. Nevertheless bibliographic
references as well as the actual training and practice deal with both classical behavioral
as well as more cognitive based methods.
The Max Planck Institute for Psychiatry in Munich, Germany, at that time headed by Prof. Johannes C.
Brengelmann, is of extraordinarily great importance concerning the promotion and implementation of
Cognitive Behavior Therapy In Europe: Germany 2
Nowadays behavior therapy tends to play a part within a general psycho-
therapeutical approach which also makes use of elements that are obtained from other
therapies – a development that is often discussed and criticized as it should affect
training concepts provided by the state.
Out-patient health services started to apply behavior therapy concepts much slower
than scientific research dealt with it as the health sector underlies administrative
regulations. The latter are stronger influenced by social-political than by technical and
Other health service sectors and psychosocial services (e.g., in-patient
psychotherapy and rehabilitation, psychosocial counseling agencies and curing in-
patient institutions) integrated new behavior therapy concepts with much more
II. Current Cognitive Behavior Therapy practice in Germany
II.1 Key sectors where Cognitive Behavior Therapy is applied
In Germany behavior therapy became extraordinarily important during the past
thirty years and it has become as relevant as psychodynamic and psychoanalytic therapy
concepts within psychotherapeutic health services. Moreover, behavior therapy is now
applied in almost every other health services sector as it has become evident that illness
has to be seen as a bio-psychosocial phenomenon. In addition to the main symptomatic
(e.g. a somatic diseases) usually interpersonal and psychological components exist
which interact with the main symptoms to a high extend. Thus, elements of behavior
therapy are now for example applied in orthopedics as well as in neurology, pediatrics
or other medical sectors and in the education sector.
While the development of psychoanalysis and of psychodynamic therapies has
mainly been influenced by physicians and while these forms of psychotherapy are
Cognitive Behavior Therapy In Europe: Germany 3
primarily applied at university faculties for medicine, precisely psychotherapy sectors,
behavior therapy can bee seen as a therapy specialization with psychological
background (Bastine et al., 1995) as it has been mainly developed at psychological
university institutes, more specifically within clinical psychology. Early concepts of
behavior therapy were primarily based on human learning theory (“behavior therapy as
applied human learning theory”), while various concepts of other psychological
disciplines were integrated later. It was medical behavior therapists in close corporation
with physicians who started to apply and re-develop behavioral concepts (Meermann,
As already mentioned, behavior therapy presumably is the most widely spread
psychotherapeutic discipline within German health services. According to a survey
conducted by Wittchen and Fichter (1980) and a survey that examined psychotherapists’
orientation towards different disciplines (Kindler et al., 1997), more than a third of all
participants were oriented towards behavior therapy.
In the following article we will introduce the German health- and social services
and sectors in which behavior therapy is applied, and we will show different approaches
to it. Initially the reader shall be informed that German out-patient therapists have to
keep their orientation towards the one main discipline they have studied and they are
officially authorized for. This is especially the case for out-patient therapy and therapy
provided by health insurance agencies; psychotherapists who teach and supervise trainee
psychotherapists are affected, as well. Restrictions of this kind result from traditional
psychotherapy regulations as well as from training regulations. Mandatory orientation
towards a certain discipline also affects in-patient therapy.
In other health service sectors (e.g. medical rehabilitation, inpatient
psychotherapy) various methods and disciplines have been integrated and mixed
together more and more so that a differentiation of different approaches does not seem
Cognitive Behavior Therapy In Europe: Germany 4
to make sense in this article. This pragmatical integration of various disciplines is
neither theoretically justified nor is it based on scientific findings. It demonstrates,
though, that further scientific research on various disciplines is required (Grawe, 1995).
II.2 Institutions that provide Cognitive Behavior Therapy
The comparatively complicated German health- and social system will here be
explained from relevant key elements and main structures. The article will not deal with
some differentiations and details, though, which results from the demand of giving a
clear and comprehensible overview on the system.
German health services
German health services supplies are usually embedded in the national insurance
system. Residents generally have to register with a legal health insurance institution
with the exception of those who can choose private insurance-membership due to
especially high income or those who underlie the state as civil servants. Health
insurance membership is usually combined with care insurance membership. Pension
insurance- as well as unemployment insurance membership automatically starts with the
beginning of the first employment as the employer is required to check if legal insurance
membership exists. Moreover, employers have to pay a legal accident insurance
membership for their employees. Legal accident insurance companies carry benefits in
the case of work-related accidents or work-related diseases.
The described kinds of insurances (Health insurance institutions, pension
insurance an unemployment insurance) run as self-government respectively autonomous
administration institutions as the state has no direct influence but just a supervising
status by laying down social laws (Vogel & Zdrahal-Urbanek, in press). An elected
internal administration team of which half of the representatives stand in for the
membership-holders and half stands in for the employers is responsible for
Cognitive Behavior Therapy In Europe: Germany 5
management- and supply matters. However, accident insurance representatives stand for
The pension insurance agencies’ job is to provide retirement payment for old-age
pensioners as well as rehabilitation measures in the case of inability to work respectively
if the ability to work is in danger. Unlike in other countries not only rehabilitation after
acute incidents (e.g., accidents, operations, and acute illness including stroke or heart
attack) but also rehabilitation in the case of chronic illness is provided. This is due to the
fact that chronic illness leads to a reduced capability in job and everyday-life and
therefore to reduced ability to work in the long-term.
Most rehabilitation treatments are provided within in-patient measures. Due to a
change of types of illnesses during the past decades the amount of measures for
mentally ill insurance members has increased. Therefore the importance of these
measures has raised up to 20-25% (Statistisches Bundesamt 2000), just following the
number of rehabilitation treatments for patients with orthopedic problems. Pension
insurance institutions provide a total of one million in-patient measures every year.
Psychotherapeutic interventions is provided both within in-patient as well as out-
patient measures (Vogel, 1996; Vogel, 1999). Within out-patient measures those
provided by psychosocial counseling agencies have to be distinguished from “ordinary”
health services measures that are supplied by legal health insurance agencies or by
corresponding replacement systems.
Psychosocial counseling is usually provided within the corresponding counseling
agencies carried by various institutions, mostly social services or municipalities.
Counseling agencies typically focus on specific tasks. Those of extraordinarily great
Cognitive Behavior Therapy In Europe: Germany 6
importance include upbringing advice centers, counseling agencies for addicts, crisis
relief centers, and marriage guidance-, partner guidance-, and sexuality counseling
agencies. Benefits are usually carried by various institutions, in many times by subsidies
of the municipalities, regional governments, or the countries’ parliaments. The
institutions often carry benefits themselves, as well.
An exact number of counseling agencies that are spread over Germany does not
seem to exist so far. Vogel (1996), though, estimates that approximately 10.000
institutions including about 10.000 all-day agencies exist. The agencies’ aim is to
provide psychosocial counseling adapted to each problem in order to find long-term
solutions. This usually includes to apply psychotherapeutic elements respectively
psychotherapy and social care intervention.
Out-patient psychotherapy provided by legal health insurance institutions,
respectively by appropriate substitute systems, has to meet very strict requirements
according to the so-called “psychotherapy-guidelines”. These guidelines have been
defined by representatives of the health insurance companies together with
representatives of the German medical doctors as well as the German psychotherapists,
and are constantly updated. These representatives have currently determined that only
three types of out-patient psychotherapy are provided by the insurance companies
including psychodynamic psychotherapy, psychoanalysis and behavior therapy. Slightly
different guidelines are valid for each of these therapies.
In each case, an application for therapeutic treatment in the form of a two- or three
pages text written up by the therapist himself is required before the beginning of the first
session. If the therapist is not a medical doctor a physician has to agree to the
application. Psychotherapy is then only provided if a psychological disorder according
to ICD-10 is ascertained and if therapy success is most likely. 45 sessions of behavior
Cognitive Behavior Therapy In Europe: Germany 7
therapy may then officially be provided for free after five initial sessions, and up to two
further prolongations for 15 respectively 20 therapy sessions can be applied for which
are free for the patient, as well.
In-Patient psychotherapy is provided in psychiatric hospitals and in clinics that are
specialized on psychotherapy and that are usually authorized as in-patient rehabilitation
clinics. The latter will be explained in more detail as this form of institution only seems
to be common in Germany.
Psychotherapeutic in-patient treatment (traditionally called “psychosomatic
treatment”) is provided by about 200 German clinics for a period of three to twelve
weeks. The insurance member has to apply for in-patient psychotherapy at the
competent insurance agency sending in an explanation by the general practitioner or the
psychotherapist alongside his application forms. If the in-patient treatment is also
approved by the insurance agency’s physician who checks the patient’s application
material, usually a personal assessment of the insurance taker has to follow. The patient
is then referred to a rehabilitation clinic that co-operates with the insurance agency.
Treatment is free apart from a required additional payment of about € 5,-- that patients
have to pay. Depending on the clinic waiting times are between four weeks and one
year. About one quarter of the psychotherapeutic clinics is officially authorized to apply
behavior-therapeutic treatment concepts and about one quarter may apply
psychodynamic oriented treatments. The other clinics adding up to hundred percent
apply various psychotherapeutic treatments.
In the clinics usually groups of ten to fifteen patients with similar indications are
formed who observe the same or very similar treatments. The patients are generally
provided with one or two psychotherapeutic one-on-one sessions per week, and
additionally a number of other health supporting treatments like sport and physiotherapy
Cognitive Behavior Therapy In Europe: Germany 8
or group psychotherapy are offered. Group psychotherapy is mainly supplied by
behavior therapy clinics where patients with similar indications like for example those
with panic disorders share groups in which they participate in group therapy sessions
and other intensive training programs (e.g., Rief, 2004, in press).
Psychiatric clinics usually only provide psychotherapy in very few cases, and if
then only a limited number of sessions. However, different measures including acute
psychiatric treatment, crisis intervention, medical drug treatment above others are
offered. On top of that many psychiatric clinics are equipped with a certain number of
in-patient psychotherapy sick-beds (usually 10-20% of all sick-beds).
III. Organizations that provide Cognitive Behavior Therapy
III.1 Deutsche Gesellschaft für Verhaltenstherapie (DGVT: German Society of
The German Society of Behavior Therapy (DGVT) was established in 1968 in
Munich as the Society for the Promotion of Behavior Therapy (GVT). Its aim was to
establish cognitive behavior therapy as a modern form of psychotherapy alike
psychoanalysis, and to organize appropriate training facilities. Just a few years later (in
1970) the Professional Organization of German Behavior Therapists (DBV) was
founded by functionary officials. This professional organization represented the interest
of trained behavior therapists and obtained the official acknowledgement of behavior
therapy for out-patient treatment as part of the medical supply system. In 1978 the two
organizations merged and the German Society of Behavior Therapy (DGVT) was
founded (Daiminger & Padberg, 2001).
The DGVT still has the role of promoting training and further training for behavior
therapists. In addition it organizes the biannual Conference on Clinical Psychology and
Psychotherapy above some other smaller conferences, workshops and further trainings.
Cognitive Behavior Therapy In Europe: Germany 9
Furthermore, the DGVT can be regarded as a health-politically active association
that strives for a psycho-social health supply of high quality. In order to meet these
demands the DGVT has been dealing with current health-political questions, has been
analyzing the health supply system, and has been obtaining experts’ opinions since its
foundation and has presented the results in public. On top of that the DGVT has made a
great effort to seek co-operation opportunities with other important organizations for
synergy effects. The DGVT was especially engaged in the psychiatry-reform of the
1970s, when the attempt to pass a psychotherapy law was first undertaken (1978). It was
furthermore engaged in establishing gender matters in psycho-social health supplies, in
the evaluation of the psychosocial supplies in the new German federal states after East-
and West-Germany had reunited in 1990, and finally in the second and successful
attempt to pass the psychotherapy law in 1998.
At present the DGVT has 4.500 members that have been recruited from all areas
of social and medical supplies as well as from the university sector. While the DGVT
used to be a federal association up to some years ago (representative office in Tübingen
since 1981) regional organizations were founded during the past three years that hold
their own membership meetings and elect their representatives independently. These
meetings have to be held at least once a year in order to vote for the federal bodies (i.e.
the commission for training and further training, the commission for acknowledgement
matters, for quality insurance, and for editorial matters, an the ethics commission.
Under the new law the DGVT has been running eight training institutions of its own
and another five training institutions in co-operation with partners. The DGVT has been
publishing a professional journal, the “Journal of Cognitive Behavior Therapy and
Psychosocial Practice”, one of the oldest professional periodicals in the German
speaking countries, for the past 35 years. The DGVT runs its own publishing house.
Cognitive Behavior Therapy In Europe: Germany 10
Furthermore, the DGVT offers training and further training for non-psychotherapists
and non-physicians as well as training that imparts specific competences.
The DGVT permanently organizes expert conferences in order to be engaged in
gender matters, antiracism matters, and counseling matters, as well as it co-operates
with other associations and the chamber of psychotherapists.
III.2 Deutscher Fachverband für Verhaltenstherapie (DVT: The German Behavior
The DVT was founded in 1992 as a succession institution of two former
organizations: the FKV and the DAVT. The main reason for the foundation of the FKV
was the new psychotherapy regulations that foresaw that behavior therapists should
participate in the out-patient supply of panel patients under certain conditions (so called
“delegation method”. While the DGVT did not accept these instructions due to
fundamental policies, the FKV welcomed the new innovation and supported it. The
latter set up training facilities for behavior therapists which enabled them to meet the
requirements that had resulted from the new regulations. The Behavior Therapy
Academy (DAVT) was then founded in 1990, and in 1995 both organizations merged
and became the DVT. Today the DVT consists of about 400 members, mainly
psychologists and physicians, and it runs 30 economically independent behavior therapy
The DVT regularly organizes scientific conferences, and it is engaged in various
committee bodies that concern relevant psychotherapy matters. Furthermore, it provides
special offers for its members such as journal subscriptions at reduced price or special
conditions for insurance membership. The members of the committee bodies discuss
matters regarding the development and optimization of training standards and current
matters regarding training institutions. Research projects in the field of behavior therapy
Cognitive Behavior Therapy In Europe: Germany 11
are supported and the optimization of quality insurance methods and programs is aimed
III.3 Arbeitsgemeinschaft Verhaltensmodification (AVM: The Behavior
The Behavior Modification Team expanded from a subdivision of the DGVT. It
was founded in 1985 with the purpose of developing more structured training facilities
as offered by the DGVT at that time. Neverless no professional or political differences
existed between the two organizations.
III.4 Deutsche Gesellschaft für Verhaltensmedizin (DGVM: German Society of
The DGVM was established in 1984 by Johannes C. Brengelmann who also
founded the DGVT and the EABT/EABCT. The DGVM is a professional scientific
union that is especially engaged in research of bio-psycho-social interactions that occur
together with diseases. Based on this research the DGVM aims to develop various forms
of medical behavior interventions that suit different diseases.
In the present the DGVM has about 200 members. According to the statutes there
are five directors. The most important body meeting is the members meeting which is
held every two years. The association’s news are published in the “Journal of Behavior
Therapy”. The DGVM is a member of the International Society of Behavior Medicine
(ISBM). Free subscription of the Journal of Behavior Therapy and the International
Journal of Behavior Medicine is included in the membership.
Since 1985 the DGVM has been organizing a scientific congress every second
year and it organized the International Congresses of Behavior Medicine of the ISBM in
in 1992 Hamburg and in 2004 in Mainz, Germany, with the support of other German
Cognitive Behavior Therapy In Europe: Germany 12
behavior therapy unions. For further information please visit the website www.dgvm-
III.5 Deutsche Gesellschaft für ärztliche Verhaltenstherapie (DAEVT: German
Society for Medical Behavior Therapy)
The DAEVT was founded in 1995 and has now about 200 members. The society’s
main purpose was to establish the concepts of behavior therapy in the German medical
support system, as the latter is politically seen of greater importance in Germany. Due to
the fact that all other behavior therapy organizations had been founded on an
interdisciplinary basis, it seemed impossible for the founders of the DAEVT to obtain
help of the other behavior therapy organizations concerning their aim to gain influence
in the medical support system.
The association’s main office is in Munich, and the members are represented in
regional groups. The DAEVT has a board of five directors. The association is especially
engaged in cooperation activities with the most significant medical and psychological
unions in order to achieve common aims. During the recent years the association’s
major tasks included quality management of behavior therapy, further training of
physicians, offers from IFA groups, quality insurance of institutional behavior therapy
trainings, the organization of scientific conferences, the promotion of behavior therapy
related, and the publication of research results.
In addition, the association is engaged in the modification and optimization of
training programs, in the adaptation of therapeutic regulations, in the implementation of
contracts between health insurance agencies and penal doctors’ unions. For further
information please visit the website www.daevt.de.
Cognitive Behavior Therapy In Europe: Germany 13
III.6 Bundesvereinigung Verhaltenstherapie im Kindes- und Jugendalter (BVKJ:
Federal Association of Behavior Therapy for Children and Juveniles)
The BVKJ was founded in 1998 and was exclusively initiated to represent interests
of behavior therapists who work with children and juveniles. The profession “Child- and
Juvenile Behavior Therapist” was only officially created when the Psychotherapy law
was passed in 1998.
The BVKJ consists of 136 members and a board of eight directors, as well as each
federal state has its own representatives. The BVKJ’s main task is the development and
establishment of behavior therapy within the age group of children and juveniles, and
furthermore, the development of treatment methods, treatment concepts and guidelines
for specific indications, providing quality insurance, and further development of
psychotherapeutic supplies of children and families.
III.7 Institut für Therapieforschung (IFT: Institute for Psychotherapy Research)
The IFT was founded by the board of the (D)GVT as a training institute of the
GVT in 1972. In 1973 it became a private and independent non-profit organization as a
consequence of several personnel and structural changes and the demand for additional
financial resources to be spent on intervention research in the field of prevention.
One important task that resulted as a further consequence was providing structured
behavior therapy training. Various short training programs were offered, and the
institute also started to organize the “Behavior Therapy Weeks” in 1978 which first took
place in Lugano and Riva (Northern Italy) and then in Freiburg, Germany, in 1980, later
in Kiel, Germany, Luebeck, Germany, and Dresden, Germany. The Behavior Therapy
Weeks consist of several parallel one- to four-day workshops and seminars that deal
with several indications as well as related treatment forms. The workshops and seminars
are held by qualified lecturers and are directed towards employees of the social and
Cognitive Behavior Therapy In Europe: Germany 14
public health sector. Fifty Behavior Therapy Weeks have taken place so far and about
25.000 people have participated. The early Behavior Therapy Weeks that took place at
times when there were only few behavior therapists in Germany can also be seen as
important social events for the behavior therapists in Germany.
Today the IFT is – apart from another renowned European research institution that
focuses on substance abuse and prevention – also an organization that provides
structured training for behavior therapy trainees which is required to become a licensed
psychotherapist. Moreover it offers additional video based training and it still organizes
the Behavior Therapy Weeks. For further information please visit the website
IV. Training, Standard Requirements, and Quality Management
Psychotherapy is a specific form of treatment for ill people. Therefore it underlies
general and specific requirements of the German medical system: Only those may
officially provide medical measures who are officially authorized by the state which
implies that they have passed the official state exam. This group mainly includes
medical doctors. Psychotherapists without medical background (e.g., those having
graduated in psychology) are only allowed to provide psychotherapy if they are
authorized naturopathic doctors. However, a naturopathic doctor’s authorization was
easy to get during the last decades. It’s only since 1999 that the psychotherapy law has
come into force, which requires psychotherapist trainees to absolve certain training
modules and which requests psychotherapists to pass a state exam in order to become
authorized. For this reason former naturopathic doctors can no longer become
As a consequence and in order to provide a detailed overview on the system the
psychotherapy training principles have to be described with regard to the occupations
Cognitive Behavior Therapy In Europe: Germany 15
backgrounds psychotherapist trainees can come from as different training modules are
required. Moreover, psychotherapy before and after the psychotherapy law has been
passed have to be distinguished from each other.
While the occupation “medical doctor” has been regulated by the German state for
some decades, psychotherapy training for physicians is provided by the Medical
Councils as part of further education programs and is regulated by the physicians’ self-
For all other psychotherapists apart from those being medical doctors no stately
requirements existed until 1998. Until then various existing psychotherapist training
institutions created their own programs and training demands and had their own
certificates. However, psychotherapists had to meet certain external demands if they
wanted to provide psychotherapy within the health insurance supply system. These
demands were formulated in the context of psychotherapy guidelines that had been
created by the health insurance institutions together with the panel doctors’ associations.
The guidelines did not only concern behavior therapy but also psychodynamic oriented
IV.1 Training Requirements for Psychologists
IV.1.1 Before the Psychotherapy Law was passed
184.108.40.206 Classical Training Structures
As already mentioned, the DGVT has been offering structured training for
psychotherapists since the beginning of the 1970s. The training structure of training that
is based on the so-called “study group model” requires that participants join regional
study groups and work out specific topics that are included in the curriculum. The
curriculum has continuously been developed and its latest version consists of 720
Cognitive Behavior Therapy In Europe: Germany 16
training hours including 500 hours theory, 100 hours encounter and self-development,
and 120 hours supervision.
The theoretic training sessions include the theory and methods of psychological and
other relevant basic subjects, theory and methods of behavior therapy, and general social
framework conditions. At least half of the encounter and supervision sessions have to be
carried out with external qualified supervisors. Every trainee has to absolve three years
of full-time experience in the psychosocial field (or longer if part-time) during the
training. Moreover trainees have to carry out a total of at least eleven behavior therapy
treatments of which four have to be documented in detail. The reports are evaluated with
regard to the professional quality by a central institution. Depending on the commitment
of the trainees, the behavior therapy training can be completed in three to five years.
A similar training concept has been conducted by the Behavioral Modification
Working Group (AVM), with the difference that external assistant professors have been
engaged to a higher extend towards the end of the training.
Additionally to the working group model based trainings - that require very self-
organized trainees – the DGVT has been offering more structured trainings in co-
operation with the Fernuniversitaet Hagen (Germany). A number of assistant professors
have been engaged with conducting the required curricula as regional training sessions
that take place during three to five years on week-ends. At the same time the encounter
and self-development sessions are held in small groups. These programs include the
same 720 training hours.
IV.1.1.2 Behavior Therapy Training in accordance with the psychotherapy guidelines
In 1966 psychotherapy in Germany was officially registered as an out-patient
treatment covered by the health insurance under specific conditions. At first this
innovation only concerned psychoanalysis. Behavior therapy was included in 1984
which required that psychotherapists had to graduate from specific officially registered
Cognitive Behavior Therapy In Europe: Germany 17
training institutions. This newly developed training program had to include a curriculum
with a total 700 training hours, including 100 one-hour supervision units with registered
supervisors and 100 hours encounter.
4.1.2 Requirements of the Psychotherapy Law
With the psychotherapy law from 1998 the profession of the psychotherapist and the
child- and juvenile therapist were legally defined. Training contents as well as the
structure of the training program of both professions are equal with regard to the basic
principles. However, unlike the training of psychotherapists the training of child-and
juvenile therapists mainly focuses on children, juveniles and their relatives. Moreover,
the latter profession requires different basic qualifications as not only psychologists and
educationists but also teachers meet the basic requirements. Child- and juvenile
psychotherapists are only allowed to treat patients younger up to 21 years, and if
required also their parents.
The training takes three to five years, and may only be provided by training
institutions of the state or by acknowledged institutes. The training includes 4.200 hours
in total, 1.800 hours of practice, 600 hours of theory, treatment practice under
supervision (600 practice- and 130 supervision sessions), and 120 encounter hours. The
remaining 930 hours are usually used for workgroup-seminars, preparations with regard
to practical treatment, feedback, and further learning-by-doing training sessions.
Practice sessions: Psychotherapist trainees have to work in a psychiatric
hospital for a period of one year and in any psycho-social institution for
another six months.
Theory: The theoretical parts that consist of lectures, seminars and hands-on
training sessions, include 200 hours of general psychotherapy knowledge and
another 400 hours of specific knowledge (e.g., Kuhr, 2004). The exact contents
are the theory and application of diagnostics, indications and planning of
Cognitive Behavior Therapy In Europe: Germany 18
treatment, treatment concepts and –techniques as well as the application of
various treatments, patient motivation, therapeutic decision making processes,
patient-therapist relationship, treatment of children and juveniles, couples,
families, and groups.
Practical training and supervision: The practical training consists of 600
one-hour treatment sessions under supervision with a minimum of six
treatments and 150 one-hour supervision sessions of which 50 sessions have to
be carried out one-on-one.
Encounter: A minimum of 120 one-hour sessions of the chosen psychotherapy
have to be consumed.
Degree: The training finishes with an official examination by the state in the
form of a multiple-choice test for the general training part and an oral exam for
the specific training part. In addition the reports of two cases have to be
handed in for evaluation.
At the moment there are around one-hundred officially registered training
institutions (in accordance to the psychotherapist law) which are able to train around
2000 students per year. Half of them are oriented towards behavior and cognitive
4.2 Further training requirements for medical doctors
Further respectively advanced psychotherapy training for physicians is regulated
in accordance with the physicians’ training regulations by the Regional Chambers for
Medical Doctors. Behavior therapy can be learned within a number of specific advanced
training modules. Each of these training concepts includes the purchase of behavior
therapy competences and the authorization to carry out psychotherapy treatment as a
practitioner. The training schedule usually requires that one main psychotherapy method
Cognitive Behavior Therapy In Europe: Germany 19
is chosen and that the relevant theoretical and practical training sessions as well as
further training sessions are consumed.
Since the psychotherapy law has been passed educationists can become authorized
psychotherapists by attending child- and juvenile-psychotherapy training courses (Borg-
Laufs & Per, 1999). This training equals the structure and the training contents of the
courses for psychological psychotherapists that were introduced above. However, the
contents stronger focus on competences regarding the requirements of interventions
with children and juveniles as well as with their parents and relatives. Therefore, the
trainees also have to gain working experience in institutions where children and
juveniles are psychiatrically respectively psychotherapeutically treated as part of their
Moreover, educationists often treat adults, for example within psychotherapy for
drug addicts. In this context numerous additional training modules are offered that are
often situated in the field of behavior psychotherapy. These additional trainings
generally correspond to the usual training requirements that were introduced in
paragraph 4.1.1. However, an official authorization for adult psychotherapy by the state
cannot be attained on this way. If such an authorization is wanted, educationists have to
attain the authorization as a naturopathic doctors like psychologists had to until a few
years ago (Niemeyer & Stähler, 2000).
4.3 Training requirements for other professions
Basic psychotherapeutical- and psycho-social competences are applied in other
professions, as well, and are therefore imparted within various training modules. These
include consulting professions like in-school consultants, schoolteachers, and job
Cognitive Behavior Therapy In Europe: Germany 20
coaches, as well as medical professions like nurses, diet consultants, and sport therapist.
Therefore, basic competences in educational therapy and behavior psychotherapy are
often provided within special training modules (e.g., role games, communication
techniques, social competence training, problem solving, and systematic behavior
modification). However, these training modules can only be seen as individual parts of a
curriculum and not as a whole degree.
5. Discussion and outlook
In Germany out-patient as well as in-patient psychotherapeutical treatment is
provided by the health system, and has been an essential part of it for the past thirty
years. For this reason different groups of psychotherapists could establish themselves
safely in public health. Psychotherapists with medical background have their own
regulated specialization, while two further professions in this field could be secured and
defined simultaneously with the Psychotherapy law of 1998.
During the last twenty years of debates regarding the public health reform some
authors demanded that certain psychotherapeutic benefits should be excluded from the
benefit list. This demand, though, has not been translated into action, and no changes
have been planned recently. Although psychotherapeutic treatment is widely distributed
in Germany only few scientific researchers have been focusing on research in this field,
and there is little evidence concerning topics like the social benefiting of
psychotherapeutic treatment or supply and demand. However, extensive scientific
research programs have been initiated by the Federal Ministry of Research and
Technology and the Federal Ministry of Health and Social Security that are expected to
change this situation within a couple of years.
Unlike in other European states and in psychotherapy research, within the
psychotherapy supply the specialization on certain kinds of psychotherapy is highly
Cognitive Behavior Therapy In Europe: Germany 21
relevant. Despite this fact, the situation is developing successfully for behavior
psychotherapists as the importance of behavior therapy has been increasing within the
psychotherapeutic sector of the health supply. This is especially notable for
psychological psychotherapists, and also – but less – significant within medical
psychotherapy and child- and juvenile psychotherapy.
Behavior therapy is the most represented psychotherapy form at university
institutes for psychotherapy and clinical psychology, while psychoanalysis and
psychodynamic psychotherapy plays the leading role at medical university institutes for
psychotherapy. This contradiction seems to be coming to an end, as professors of
behavior therapy have recently been engaged for leading positions at medical university
institutes in order to promote the exchange of professional experience in therapy related
The Psychotherapy law has assigned the psychotherapy specialization, which was
mentioned above, for the training of both new psychotherapeutic professions. However,
the law also requests that basic knowledge concerning all kinds of psychotherapy is
taught as part of the training. This may have established the ground for integrated
Future progress and development should include several topics. While the training
requirements of medical psychotherapists are easily determined and updated internally,
changing the training demands of psychological psychotherapists and child- and
juvenile therapists is slightly more difficult. Specifically, the latter are assigned by
federal laws and can only be reformed under certain political constellations despite
permanent criticism by experts. This problem could have an effect on the demand for
psychotherapy training (currently very expensive, about 20.000 EUR), and a slight
tendency towards that can already be recorded.
Cognitive Behavior Therapy In Europe: Germany 22
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