7.4.04 Cognitive Behavior Therapy in Germany Heiner Vogel & Julia Zdrahal-Urbanek University of Würzburg, Institute for Psychotherapy and Medical Psychology I. Introduction 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. 1 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 behavior therapy d:\docstoc\working\pdf\56502f86-05b8-4aa5-9319-641f5aafe668.doc 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 scientifical impulses. 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 enthusiasm. 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, 1997). 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 employers only. Pension insurance 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 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 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 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 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 Behavior Therapy) 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 Therapy Unit) 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 training institutions. 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 at. III.3 Arbeitsgemeinschaft Verhaltensmodification (AVM: The Behavior Modification Team) 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 Behavior Medicine) 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- online.de. 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 www.ift.de. 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 psychotherapists. 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- governing bodies. 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 psychotherapy. IV.1 Training Requirements for Psychologists IV.1.1 Before the Psychotherapy Law was passed 18.104.22.168 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 therapy. 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. 4.2 Educationists 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 training. 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 research projects. 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 psychotherapy training. 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 References Behnsen, E. & Bernhardt, A. (1999). Psychotherapeutengesetz. Erläuterte Textausgabe zur Neuordnung der psychotherapeutischen Versorgung. Köln: Bundesanzeigerverlag. Borg-Laufs, M. & Per, G. (1999). Die Ausbildung in Kinder- und Jugendlichen- Verhaltenstherapie. In M. Borg-Laufs (Hrsg.), Lehrbuch der Verhaltenstherapie mit Kindern und Jugendlichen, Band 1: Grundlagen, (S. 587-605). Tübingen: DGVT. Daiminger & Padberg (2001) DGVT-Geschichte. Verhaltenstherapie und psychosoziale Praxis (wird ergänzt) Grawe, K. (1995). Grundriss einer Allgemeinen Psychotherapie. Psychotherapeut, 40 , 130-145. Kindler, R., Tönnies, S., & Wilker, F.-W. (1997). Zur Aus- und Weiterbildung sowie beruflichen Situation Klinischer Psychologinnen/Psychotherapeutinnen und Klinischer Psychologen/Psychotherapeuten. Report Psychologie, 51, 774-787. Kuhr, Armin (in press). Strukturqualität in der Verhaltenstherapie-Ausbildung und ihre Sicherung. In A. Laireiter & U. Willutzki (Hg.), Ausbildung in Verhaltenstherapie. Göt- tingen: Hogrefe. Meermann, R. (1997). Biologie- und medizinhistorische Wurzeln der Verhaltens- therapie. Praxis Klinische Verhaltensmedizin und Rehabilitation, 10, 45-51. Niemeyer, F. & Stähler, T. (in press). Auswirkungen des Psychotherapeutengesetzes auf die Kriterien des VDR für Ausbildungen zum Suchttherapeuten. Verhaltenstherapie und psychosoziale Praxis, 32,welche Seiten? Rief, W. (2004) Stationäre Psychotherapie. In: Hiller, Sulz, Leibing (Hrsg.). Grundlagen der Psychotherapie. Band 1. München, CIP-Medien. Cognitive Behavior Therapy In Europe: Germany 23 Vogel, H. (1996). Ambulante Psychotherapieversorgung - eine kritische Übersicht. Verhaltenstherapie und psychosoziale Praxis, 28, 105-126. Vogel, H. (1999). Verhaltenstheoretische Ansätze in der Gesundheitsversorgung. In H. Reinecker, M. Borg-Laufs, U. Ehlert, D. Schulte, H. Sorgatz, & H. Vogel (Hrsg.), Lehrbuch der Verhaltenstherapie,S 15-43. Tübingen: DGVT-Verlag. Vogel, H. (2000). Das Psychotherapeutengesetz und die Ausbildung der Psychothera- peuten. Journal für Psychologie, 8 , 41-53. Vogel, H. & Zdrahal-Urbanek, J. (in press). Rehabilitation in Germany. New challenges of a structured security scheme. Wittchen, H.-U. & Fichter, M. M. (1980). Psychotherapie in der Bundesrepublik. Weinheim: Beltz.