NPCE
Event 2024: Digitalization
and Artificial Intelligence in Psychotherapy
How do digitalization of healthcare and artificial intelligence tools affect psychotherapeutic care in Europe? This question has been discussed with experts at the annual event of the Network for Psychotherapeutic Care (NPCE) on 29 May 2024.
Dr. Nikolaus Melcop, Vice President of the German Federal Chamber of Psychotherapists (BPtK), opened the event and explained that recently adopted EU Health Data Space Regulation has created a set of rules that enables the exchange of digital health data across Europe. It also facilitates the use of data for research purposes. This is particularly important for the development of AI-based applications in healthcare. Digitalisation in healthcare is necessary. However, digital applications must be proven to be effective and safe. First and foremost, digitalisation in healthcare must benefit patients - and not only commercial interests, Dr. Melcop said. Moreover, digital applications can only improve mental healthcare if they are embedded in local psychotherapeutic care. Regarding the use of artificial intelligence in psychotherapy, it needs to be scrutinized in how far and to which extent such tools can be used, and which ethical aspects need to be considered.
AI in psychotherapy? Not today, but in the future.
Prof. Dr. Harald Baumeister, University of Ulm, respond to this question. The psychological psychotherapist undertakes various research on digital applications in mental healthcare, especially in psychotherapeutic care. He pointed out that the development of AI-based applications has been taking place since the 1950s. However, when we talk about AI-based applications in psychotherapeutic care today, these are usually not actual AI applications, but merely algorithms. AI has therefore not yet played a role in psychotherapeutic care. In the future, AI-based chatbots and digital health applications could supplement psychotherapeutic care. But so far, there is no or not sufficient evidence of their effectiveness and safety. Prospectively, in the field of diagnostics AI tools could also assist psychotherapists. Baumeister underlined that ethical aspects must be considered while developing AI tools and their implementation. It must be assured that AI applications are transparent, that they do not reproduce discrimination and do not lead to misinterpretations. However, legal standards on data protection and privacy also influence how AI applications are developed. In view of the large investments being made by the USA and Asian countries, AI applications will primarily be developed out of commercial interests. Still, AI offers the opportunity to gain new insights into mental illnesses and can facilitate the development of individualized treatments, i.e. even more precise psychotherapeutic treatment. In the discussion of the participants of the event, the question arose which risks need to be taken into account when using AI in psychotherapy. The participants agreed that it is important for the profession to be continuously involved in AI development from the outset, in testing AI applications, and to be able to assess which AI applications are potentially indicated and safe for patients.
Digitalisation can support psychotherapeutic treatment
In her presentation, Maria Karekla, University of Cyprus, pointed out that study results always describe an average patient. This means that individual aspects that could be important for treatment get lost. However, the individual perspective must also be stronger considered in treatment. Patients perceive differentiated symptoms in everyday life but are not always able to address them in the psychotherapy session. As a result, psychotherapists cannot include these important insights in the treatment of a patient. A solution is digitally supported monitoring and documentation. By using a digital application patients can note down at any time how they feel and which symptoms arise. This can be analysed and thus, incorporated into treatment by psychotherapists. There are already many digital applications that can be used for this purpose. One example is smoking cessation. Digital applications could help to classify the patient's experiences and problems when quitting smoking and keep up the patient’s motivation. In Karekla’s view, virtual realities could also be a means of simulating certain challenging situations in psychotherapy in the future. It could be used to directly instruct patients on how to overcome or deal with specific situations. The range of digital applications, from apps to virtual reality, is wide and could offer opportunities for mental healthcare. However, if these tools are beneficial for patient treatment will depend on their further development.
Identification of safe and beneficial digital applications by guidelines
The participants then exchanged views on current developments in European countries. The use of digital applications and the development of new products are progressing continuously. The market is primarily determined by the industry, which develops and launches products very quickly. At this pace, it seems impossible for public research and development to keep up. It is therefore essential for psychotherapists to have knowledge and guidelines that enable them to identify evidence-based digital applications that are safe and useful for patients. Then, they can decide whether digital tools can be used in psychotherapeutic care.
28/04/2023
NPCE Event 2023: Psychotherapeutic and psychological expertise is needed to tackle climate crisis
On 18 April 2023, the Network for Psychotherapeutic Care in Europe’s (NPCE) symposium about the climate crisis and its impact on mental health took place digitally. Psychotherapists from all over Europe discussed how the climate crisis relates to mental illness, what contribution clinical psychologists and psychotherapists should make in the climate crisis, and how psychological or psychotherapeutic emergency care could be strengthened in climate-related natural disasters. BPtK Vice President Dr. Nikolaus Melcop noted that the effects of climate crisis were already noticeable throughout Europe, such as through periods of heat and drought or flooding, and that these events were also having an impact on mental health.
The climate crisis is a psychological crisis
For Friederike Schwarzkopf, psychotherapist and member of Psychologists/Psychotherapists for Future (Psy4F), the climate crisis is a psychological crisis. In her presentation, she outlined how psychologists and psychotherapists worldwide can support society to act in a more climate-friendly way. Psy4F educates about the effects of climate crisis, supports climate activists through psychotherapeutic interventions, participates in protest actions itself and writes publications on the climate crisis. One focus is also the development of psychotherapeutic services for coping with climate anxiety. The climate crisis and its effects are complex. This poses the risk that the dangers of the climate crisis are ignored, minimized, or even underestimated, so that opinions can sometimes vary greatly as to whether and how the need for action is assessed and which measures are considered necessary. At the same time, the climate crisis can also be perceived as a too big and seemingly insoluble problem. Activism and networking are important to generate awareness and change the society. From Psy4F's perspective, media coverage plays an important role in keeping the pressure for action high, but also in acknowledging concerns and fears associated with the climate crisis, as well as highlighting coping strategies. With their expertise, psychologists and psychotherapists can make an important contribution to overcoming the climate crisis. They can help to better understand the effects of the climate crisis on mental health and to strengthen coping strategies. The profession's voice is also important in supporting social change toward greater climate justice, she said. To this end, the profession should actively engage in societal discourse, advance the prevention of mental illness, including the formulation of guiding principles for a world that supports mental health. In addition, it is also important to further develop crisis interventions, to integrate the climate crisis and its consequences into education and trainings of the profession, and to advance research.
Constructing a sustainable renaissance
Alberto Zucconi, president of the Person Centered Approach Institute (IACP) in Rome and co-founder of the World Sustainability Forum (WSF), also highlighted that mankind is responsible for the climate crisis and action must be taken now to address its consequences. For far too long, the effects of planetary destruction by humans have been denied or not taken seriously. The climate crisis is a growing global threat. Clinical psychologists and psychotherapists must ask themselves whether they want to be part of the problem or part of the solution. It is not enough to focus only on the treatment of mental illnesses resulting from the climate crisis. Clinical psychologists and psychotherapists have to educate about the consequences of the climate crisis, because these are directly linked to mental health. In particular, eco-psychology should be more integrated into the profession's curricula. Clinical psychologists and psychotherapists are also important in helping communities better cope with changing realities. Zucconi promotes a bio-psycho-social-spiritual approach that focuses on the relationship and interaction between people and with nature. Respect, empathy, and the ability to form close bonds also allow people, communities, and cultures to feel connected to each other and to the planet. Clinical psychologists and psychotherapists can and should play an important role in shaping a "sustainable renaissance."
Regional psychological emergency in climate disasters
Portugal has established a psychological emergency service to support people in psychological crisis. Sónia Cunha, coordinator of the Portuguese Center for Psychological Support and Crisis Intervention (CAPIC), reported that four centers with a total of 24 clinical psychologists provide emergency psychological care to citizens nationwide 24 hours a day by telephone and also conduct outreach. She added that psychological crisis service is also of great importance during climate disasters, such as the devastating forest fires in Portugal in 2017. As part of the integrated medical emergency team, the psychological emergency service ensures that the psychological needs of the affected population are also met in addition to the medical needs in catastrophes. At the same time, one focus of their work is to help rescue forces to cope with their experiences and prevent post-traumatic stress disorders. As a result of the severe forest fires, the Portuguese Ministry of Health assembled a working group with the aim of identifying care needs and developing a concrete catalogue of measures. Thus, regional mental health crisis centers were introduced, as locally based mental health teams could meet the specific care needs in the region, can properly help strengthen resilience in communities and teach to cope with future disasters.
Commitment of the profession
The NPCE members reported that the challenges of the climate crisis on mental health are widely under discussion, including the role and professional duty of clinical psychologists and psychotherapists. The NPCE members expressed their support for climate action and commitment by the profession to address and cope with the climate crisis and its associated mental health threats. It is a professional duty to participate in the preservation and promotion of ecological and socio-cultural livelihoods with regard to people's mental health.
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05/07/2022
NPCE Event 2022: Psychotherapeutic care for refugees in the EU
Psychotherapeutic care for refugees in the EU was the topic of this year's symposium of the Network for Psychotherapeutic Care in Europe (NPCE). Under the chairmanship of Dr. Nikolaus Melcop, Vice-President of the BPtK, international experts discussed which challenges exist in the care of mentally ill refugees and how treatment can be ensured. Dr. Nikolaus Melcop explained that in the current situation it should not be forgotten that there are both Ukrainians and many other refugees seeking protection in Europe. There should be no distinction between refugees. Access to psychological and psychotherapeutic treatment must be guaranteed for all, regardless of their origin.
Specific needs of Ukrainians
Dr. Viktoriia Gorbunova, clinical psychologist at Ukrainian Catholic University, and Dr. Vitalii Klymchuk, mental health expert at the Ukrainian Ministry of Health, outlined the specific factors that should be considered in the care of Ukrainians. People experience various traumas; it is important to identify and treat them in time. In addition to psychological and psychotherapeutic help, social work and legal support are also necessary. Many Ukrainian refugees have relatives who have remained in Ukraine or must fight in the army, about whom they are worried. People are also concerned about whether to leave the country or when to return. Maintaining contact with relatives is therefore crucial and can be supported by free telephone calls. For some Ukrainians, even the Russian language might be retraumatizing. Therefore, Ukrainian-language counselling and care services should be available. Opinions about Russia as well as values and political attitudes towards war, knowledge about how to deal with aggression, hate and other emotions that are normal in times of war should also be taken into account by professionals. When involving Ukrainian specialists, it should be ensured that they have the necessary qualifications to ensure the quality of treatment. Video treatment is important to maintain care. Especially for soldiers, this is a suitable low-threshold form of treatment.Group-based stress management for refugees
Claudette Foley, community psychologist, presented findings on the use of the group-based stress management course for adults "Self Help Plus (SH+)" developed by the World Health Organization (WHO). SH+ focuses on stress management for people who have experienced humanitarian crises. It is transdiagnostic, low-intensity and thus almost always safe for most the majority of people at most times, can be used in low-resource settings, and can be performed by trained laypersons. In addition, it takes into account cultural specifics. Studies have demonstrated that SH+ participants showed a lower risk of developing a mental disorder. SH+ is characterized in particular by its low-threshold nature, its cultural resonance, and the fact that it can be offered to many people. SH+ facilitators do not need to be professionals; they are primarily trained to assist, read out discussion questions and ensure interactive group work, provide guidance, and give culturally relevant explanations. SH+ facilitators do not provide counselling or therapy.Train professionals to care for refugees
To provide good care for refugees, professionals need to be trained, says Iga Jaraczewska, a lecturer at Akademia Motywacji i Edukacji (AMiE). Not all psychologists and psychotherapists are experienced in treating traumatized refugees. These colleagues should be educated about which therapeutic measures are effective and which are ineffective. Also, it must be questioned to what extent standard treatment is sufficient to meet the care needs of refugees who have experienced war and terror. Guidelines and research on refugee care need to be promoted. AMiE has provided training for professionals and volunteers working with refugees to strengthen the specific skills required. The focus was primarily on practice rather than theory. Care for refugees also need to include how to dress, how to overcome language barriers, what customs and behaviours need to be acknowledged, and whether beliefs or religion needed to be considered, as well as gender issues.Care requires cultural and language mediation
Teresa Sousa, a clinical psychologist at the Portuguese Refugee Council, provides psychological care for refugees. Before she can work with refugees, it must first be clarified which language is spoken and whether the patient is comfortable with an interpreter. Gender-specific aspects must also be considered; for example, only a female interpreter should be consulted. If a patient refuses an interpreter, it is important to find out the reasons, understand them and build trust. In the cooperation with language and cultural mediators, training and supervision are needed to avoid mistakes in interpreting in the therapeutic setting on the one hand, and to prevent psychological stress for the interpreters on the other. For the care, the value system of the patient must be understood, but also concepts of culture and society must be questioned. Psychotherapy is not well known in all countries; therefore, refugees must be better informed about the benefits and trust-building measures must be brought into focus.NPCE calls for joint EU action
Mental health is a basic human right and essential for the well-being as well as the integration of refugees into society. Therefore, the EU must work with the member states to ensure that all refugees receive the care they need, regardless of their origin or residency status. This includes prevention, psychological primary care, and psychotherapeutic treatment, as well as language mediation and digital solutions. Common standards for mental health services should be developed and implemented in the EU, exchange of best practice and guideline development should be promoted. It must be ensured that quality standards are met, and care is provided by qualified professionals. Also, interdisciplinary approaches that can address the diverse needs of refugees should be promoted. To monitor the provision of care for refugees in the EU, member states should be required to report publicly about their activities at the EU level. Sufficient financial resources are needed to manage crises, but also joint mental health crisis plans are required. These should be developed together with clinical psychologists and psychotherapists.Country reports
Germany
In Germany, refugees are generally not legally entitled to psychotherapy during the first 18 months of their stay. As a result, many of them do not receive treatment and their illness worsens. The Asylum Seekers' Benefits Act (Asylbewerberleistungsgesetz) must be further developed so that mentally ill refugees have a right to psychotherapeutic care, regardless of how long they have been in Germany. Refugees from Ukraine who receive temporary protection have been covered by statutory health insurance since 1 June 2022 and are thus entitled to psychotherapy. However, the language and cultural mediation that would be necessary for diagnosis and psychotherapeutic treatment is not yet paid for by the health insurance companies. It is urgently needed that the costs for interpreters in psychotherapeutic treatment must be covered by the statutory health insurance funds. Model projects for language and cultural mediation are only a temporary solution because they have limited financial resources and can only cover part of the care. The federal government should strengthen corresponding initiatives financially in the short term until language mediation is anchored in the social security and healthcare system.
The treatment capacities for mentally ill refugees are limited. For this reason, psychotherapists who are not licensed by the statutory health insurance funds must be authorized to provide treatment to refugees in order to increase the number of treatment options or to enable mother-tongue care. In addition, the health insurance companies must abandon their restrictive practice of approving applications for reimbursement in private practices. Only in this way can traumatized and mentally ill refugees be helped quickly. In addition, financial support must also be provided to the psychosocial centres for refugees and victims of torture, which are often the first point of contact for mentally vulnerable and ill refugees.
Since the asylum law reform of the last federal government in 2016, post-traumatic stress disorder (PTSD) is no longer generally considered a serious illness that can prevent deportations. The assumption that PTSD does not pose a significant and concrete threat to life and limb is technically incorrect. It is precisely the removal to a country in which the refugee felt or even still feels his or her life is threatened that can trigger suicide. It must be made clear that PTSD can in principle also constitute a removal ban. With the "Ordered Return Act" (“Geordnete-Rückkehr”-Gesetz) of 2019, it was determined that in the future only opinions of physicians will be considered when assessing whether a refugee may not be deported due to a serious mental illness. Since then, opinions of psychotherapists are no longer recognized in asylum procedures. Psychotherapists are licensed to assess mental illnesses. Any professional expertise provided by a recognized medical profession should therefore be considered in asylum proceedings.
Greece
Greece has been one of the main countries in the Mediterranean which have received an unprecedented number of refugees, asylum seekers, and displaced people, currently hosting more than 50.000 refugees. While many refugees exhibit impressive resilient and psychological flexibility despite having experienced multiple personal adversities or traumatic related conditions, their capacities to cope with daily challenges can reach a limit, beyond it, their mental health can be put at threat.
Mental health problems of refugees (data)
There are no official statistics about the mental health of refugees, but reports from supporting organizations, present a concerning increase in mental health problems of refugees. For example, according to the International Rescue Committee (IRC, 2020) and its work in collecting data (n=904) over the last three years in the three main refugees’ holding centers (camps) in the islands of Lesvos, Samos, and Chios, “as many as three out of four of the people, the IRC has assisted through its mental health program on the three islands reported experiencing symptoms such as sleeping problems, depression, and anxiety” whereas depression, post-traumatic symptoms, and self-harm have been reported among people across ages and backgrounds (IRC, 2020). These numbers are even increasing and alarming, following the pandemic, where a 66% rise was noted in the number of asylum seekers, reporting symptoms of post-traumatic stress disorder (PTSD), self-harm, and depression (IRC, 2020). The authors report potential reasons for these mental health problems, laying, partly because of several contextual parameters, including bad hygiene and other conditions in the camp, lack of main services, and involvement of refugees in complex bureaucratic procedures.
Albeit these concerning results, it should be noted that most of the emotional suffering is directly related to current stresses and worries, and uncertainty about the future (NHPSS, 2020). Most of the Mental health services in Greece for refugees, as shown below, follow the international key principles for promoting mental health and psychosocial well-being, viewing a refugee or a migrant as not exclusively more vulnerable to mental disorders on the ground of by itself being a refugee or an immigrant, but as individuals with an increased risk to stressrelated exposure conditions (e.g., abrupt and violent move from home, multiple losses, etc.).
Mental health support provision
The refugees and asylum seekers have the right to access public health services and psychiatric support through the national health system (ESY) which is made up of a mix of health service providers, broadly divided into primary, secondary, and tertiary tiers of service delivery (L 4378/2016). Despite the supporting legal framework, providing access to mental health services to refugees and asylum seekers, actual support provision to health care services is limited due to consistent barriers, including unstaffed services, availability of translators or cultural mediators, lack of services provision to cover the needs of a different group of the general population and persons without social insurance or vulnerable groups, and bureaucratic difficulties, such as delays of public health authorities to provide foreigner’s temporary insurance and health coverage number (PAAYPA).
Supporting organizations provide on-demand Mental Health and Psychological Support (MHPSS) services to refugees either as part of an on-campus clinic (e.g., in the largest campus clinic in the Kara Tepe area on the island of Lesvos) or in the local services in partnership with other actors active in the mental health field (e.g., in public community centers, hospitals or in collaboration with other actors supporting refugees, such as UNCHR, Caritas Hellas, ELiL, IsraAID, Iliaktida, PIKPA, IRC, KEP, IKA, EODY (former KEELPNO), RIC secretary, Asylum Service, EASO, PRAKSIS, MSF, ERCI, BRF, SMH, ARSIS and DRC).
Considering the difficulties refugees face to access public health psychosocial support services, the non-governmental organization (NGOs), such as the “babel” (https://babeldc.gr/en/homepage/ ) and the Doctors of the World / Médecins du Monde – Greece (MdM-Greece; https://globalcompactrefugees.org/article/quality-healthcare-andpsycho-social-support-refugees) have set up inclusive and free mental health and prevention supporting services to refugees.
There are variations in terms of the mental health services different providers support. For example, while in public mental health services the provision of service occurs mainly for those with a satisfactory level of fluency in the Greek language or provision given in the English language, other supporting organizations (e.g, Babel) accept anyone who has difficulty accessing or are being excluded from mental health services. Further, NGOs can provide support via different channels (e.g., via telephone, in person, or through other professionalusuals, such as the translator or the cultural mediator) and multidisciplinary professions (e.g., psychologists, social workers, etc.), whereas public health services limit their capacities mostly in in-person scheduled sessions (usually an appointment with a psychiatrist scheduled 2-4 months before the actual session, excluding the emergencies) and most often without the presence of the mediator or translator. Further, while public mental health services focus on symptom alleviation, medication prescription, and monitoring, other supporting organizations attempt also to empower resiliency, flexibility, and healing based on lessons learned, and to promote experienced processing, as well as the construction of new meaning and reorganization of individuals’ lives via copious influences, interactions, and social narratives.
NGOs and supporting organizations tend to respond more flexibly to mental health requests, often attempting to resolve the request with sensitivity and personalization. This reflects a more inclusive work framework where individuals’ requests are treated with compassion, respect, and understanding with professionals focusing on the needs with cultural sensitivity and competency. For example, referrals concerning drug and alcohol use are referred to specialized centers and so do referrals for severe trauma).
Psychological Intervention practices in Greece
As it is unanimously agreed that there is no single model or framework to provide mental health support to refugees and immigrants on the move to Europe, the main organizations supporting immigrants in Greece seem to adhere to internationally agreed evidence-based practices of mental health support provision. A scoping brief narrative review indicates the following with regards to the support services in Greece for refugees. Most of the organizations seem to:
- Treat all people with dignity, support, and respect,
- Provide some type of psychological first aid (PFA), using simple rules and techniques to respond to individuals’ distress,
- Supply refugees and immigrants with updated factual information about where and how assistance can be obtained,
- Provide relevant psychoeducation in languages that people can understand (e.g., the sexual and reproductive healthcare-SRH- and support for survivors of sexual and gender-based violence-SGBV services provided in Kara tepe camp in Lesvos by the MdM- UNHCR),
- Prioritize some protection and psychosocial support for children particularly those who are separated, unaccompanied, and with special needs (e.g., Caritas day center for child refugees in Athens)
- Some mental health services are now being provided remotely, including through multilingual telephone hotlines or over the internet through online sessions.
With regards to the psychosocial interventions, cognitive-behavioral interventions, in particular, narrative exposure therapy and other relevant interventions seem to be the most familiar therapeutic approaches employed by various professionals, although more training and thorough supervision are needed as most of the psychology staff working with this population is young and not well-trained with post-graduate degrees and specializations. There are services which make use of psychodynamic or humanistic-existential approaches or approaches based on the expertise the staff members exhibit. For those with severe and complex mental health conditions, mental health support is provided either remotely (online) or directly in safe ways, including monitoring of medication and continuation of treatment adherence.
Most of the refugees across the world (e.g., 84%), are hosted in developing regions and their access to quality mental health care is already very limited. After the pandemic where coronavirus causes great physical and mental affliction, the need to invest in continued health services, including mental health, and ensuring their accessibility to all is as evident and critical as ever.
References:
IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: Inter-Agency Standing Committee. 2007
World Health Organisation Regional Bureau for Europe. Policy brief on migration and health: mental health care for refugees. Copenhagen: WHO-EURO, 2015.
Turrini, G., Purgato, M., Ballette, F., Nosè, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International journal of mental health systems, 11(1), 1-14.
Papadopoulos, R. (2021). The approach of Synergic Therapeutic Complexity with Involuntarily Dislocated people. Systemic Thinking and Psychotherapy, 18.
Federica Micoli, F. M. (2022). Human Rights practitioners’ approach to refugees and migrants. A therapeutic psychosocial perspective (Doctoral dissertation, University of Essex).
Hungary
In the period following the outbreak of the Russian-Ukrainian conflict, a significant proportion of refugees arrived in Hungary. According to the data of the United Nations, approximately 570,000 Ukrainian refugees have arrived in the country since the start of the war. In comparison, 20,000 refugees have applied for asylum in Hungary, which is a low rate in Europe. This is not explained by the fact that 80 percent of the refugees in Hungary do not want to wait for the end of the war.
On the other hand, both the psychiatric care system and professionals working in private practice reacted quickly to the situation. Many Hungarian psychologists, psychiatrists and mental health professionals have joined the initiative to offer psychological assistance to Ukrainian people fleeing the war to Hungary. Multilingual access to counselling is available by phone, online or in person, and is free of charge. As written in the call published on pszi.hu, all this does not necessarily mean psychotherapy or psychiatric care, but counselling, helping and supporting conversation. The website provides access to a number of professionals, as well as the format and language in which they provide assistance. The Crisis Intervention Outpatient Clinic of Péterfy Hospital also aid the refugees: according to their call, psychologists and psychiatrists of the hospital provide pro bono crisis intervention (in Hungarian and English) and, if necessary, medical assistance as well. Finally, opioid substitution treatment centres have included opioid-addicted refugees in their methadone and buprenorphine programs.
Italy
In Europe there is an humanitarian emergency with millions of people forced by wars and misery, to escape and try to find safe havens by take long & risky trips that take long periods of time during which migrants suffer abuse and violence of all kinds. Many die in their attempt to reach safety.
In Italy, urgent healthcare is provided to everyone, even to undocumented people. If you are an asylum seeker, a refugee, or you hold subsidiary protection status, you are entitled to access health services on the same basis as Italians. You must register with the Italian public healthcare system (SSN). Once registered, you will receive a health card and you will have the right to: a family doctor or pediatrician, specialized medical visits, blood tests, vaccinations, hospitalization, and other different kind of health treatments, depending on your needs. Specialized health care, including mental health support, that you can book through the healthcare booking services.
The Italian system has a dedicated network of assistance services for mental health that you can access through your medical doctor. On the website of Ministry of Health you can also find the list of DSM (Department of Mental Health).
THE United Nations Refugees Agency UNHCR reports that at the end of 2021, there were 89.3 million people fleeing war, violence, persecution and human rights violations, an increase of 8 percent from the previous year and well over double the figure recorded 10 years ago, according to UNHCR's annual Global Trends report.
The Russian invasion of Ukraine and other emergencies have pushed the figure over the dramatic 100 million mark. As of 7 June 2022, there have been approximately 7.3 million border crossings from Ukraine and another 2.3 million crossings to return to the country. In Italy there are just over 80,000, the figure is current as of 25 May 2022 Ukrainian citizens who have applied for a residence permit for temporary protection, mostly women and children. In total, there are almost 39,000 Ukrainian minors who have requested temporary protection in Italy, just under half of the total. The data about Italy come from the Italian Civil Defense, which, confirming the good practice started with the beginning of the pandemic by Covid-19, has decided to publish in an open format data on the reception of those fleeing Kiev. Data that allow us to see how entries into our country experienced a peak in the first days after the invasion, and then decreased as the weeks went by.
The burden of trauma caused by the invasion of Ukraine is staggering before the pandemic of Covid-19. UNICEF calculated that each year 28 million of children are victims of trauma, and if not properly treated by expert mental health professionals their trauma will bring catastrophic consequences of their health on social health and the mental health of future generations. Now with the Covid-19 and the Ukrainian invasion, the burden of trauma is going to double up. Furthermore, if health professionals are not properly trained there is the risk of non-intentionally provoking iatrogenic damage and retraumatising the patients already victims of trauma. Nowadays we have safe, person-cantered approaches that are trauma-informed best practices.
Trauma informed best practices are crucial for the effective prevention and treatment of trauma.The scientifically formulated trauma-informed best practices exist for psychotherapists, medical doctors, pediatricians, psychiatrists, clinical psychologists, teachers, managers, nurses, volunteers, community officers, police officers, directors of services and juvenile delinquency personnel, judges and policy makers. In other words, each of those roles can do a lot to reduce harm and to refer people that for an ignorant professional may just look as unacceptable acting outs or lack of discipline that are to an educated eye symptoms that suggest referral to a well-trained trauma-informed mental health professional.
The Person Centered Approach Institute (IACP), where they train mental health professionals in trauma informed best practices and the Faculty of Psychology of the University of Turin (UNITO) will train totally for free of charge the first group of 15 Ukrainian psychotherapists wishing to become trainers in this field that is crucial for the health and wellbeing of the present and future generations.
Portugal
Preamble: The political context in Portugal is stable, and the Portuguese population have on long term a positive attitude regarding the refugee’s welcome, availability to provide voluntary help and giving support towards policies in order to promote their social integration.
The legal framework: The refugees are entitled for psychotherapeutic treatment in the same conditions as the national citizens. The main governmental Agency for Health Care, DGS, has published a directive covering the availability of the National Health Service access to all the refugees. The public health care services, following the DGS directive, promote equal access for the refugees and national citizens. The DGS manual for the psychosocial support for migrants, recommends the use of cultural mediators, for what it will be needed provided specialised training.
After the pandemic emergency, there was significant improvement of online psychotherapy, which could be useful with treatments for refugees dislocated from the city centres or health care facilities.
What is no longer available: A psychiatric service with an open consultation dedicated to migrant and refugees with a transcultural perspective.
What is still missing: The public health care service in Portugal is in a permanent deficit on material and human resources, mainly in the specialised field of mental health care. Specialised training of psychologists, psychotherapists and other health care professionals is needed, as well as decentralized clinical facilities with mediators and interpreters.
What is new in 2022: The previous required payment of moderation taxes for the services access was generally abolished. There is now a list of mediators and interpreters available to attend the requirements in clinical and social context.
We had in Portugal already a community of Ukrainians very well integrated. From the other side of Europe, more than 40.000 people arrived in a few months after the beginning of the conflict in Ukraine and were welcome. Arriving in Portugal, their problems are being perceived, in same accuracy as ours. The war in Ukraine and the wave of refugees gives to the problematic mental health a special relevance, and a new sensation of proximity. The traumatic experiences of the refugees give new relevance to mental health and the need of early intervention to prevent serious psychological disturbs. The political acknowledgement of this issue is required to make available psychotherapeutic care in Portugal to the general population.
The actual situation of war in Ukraine impacts not only the refugees arriving in Portugal, but also in the national and other residents in Portugal with different levels of psychological sufferance and fragility which demand measures for adequate scanning and psychotherapeutic support. Even if it was possible to give a first emergency psychological aid and psychotherapeutic care to refugees and migrants, it will be necessary to set up permanent structures providing specialised care, articulating the work of the ACM, the Higher Commissariat for Migrants, with the DGS, the main governmental agency responsible for Health Care Services.
It will be relevant if a national network with all interested on this subject, public and private and others already on the field could build a channel of communication centralising the resources available in an open platform and share their expertise. To face the emergency of war in Europe, with different gradations of contingencies with severe impact on mental health, we need not only contingency measures, but with urgence outline structural changes in the services of mental health care.
Best Practices: An informal network platform, PAR, has remained since 2017 operative giving support to refugees. The Chamber of Portuguese Psychologists has published a tutorial/manual of good practices for professionals which are working with refugees.
The Portuguese Centre for Refugees, CPR, has set up a psychological support specialised for refugees. A transcultural approach consultation and institutional supervision is now available provided by the CEC, a transdisciplinary group of academics and professionals.
Switzerland
Swiss Refugee Policy: The numbers of refugees in Switzerland are increasing every year. In May 2022, the number of officially recognised refugees was 74,047. But the numbers of refugees staying in Switzerland for a longer time is decreasing since 2016. The main reason seems to be that Switzerland is only used as transition country to other destinations. The Swiss asylum law follows the UN refugee convention of 1951. The first asylum law became effective 1981. Since then, it was revised several times with a tendency to make it stricter.
Psychotherapeutic Supplies for Refugees: The main goal is to provide easy access for refugees to these supplies. They are short time interventions that usually don’t last longer than 3 months, the intensity varies. They consist of psychoeducation and aim to stabilize the refugees and activate their resources. The interventions are provided by either psychotherapists, psychiatrists or trained peers or laypersons. They can either take place where the refugees live or online or in other places. Currently there are 10 officially recognized projects which have this approach.
- STARK: a group programme to provide skills for the regulation of emotions, especially for single unaccompanied underaged males, lasting 14 weeks and taking place in the refugee facilities once a week for 90 minutes during school time, performed by a psychotherapist or psychiatrist.
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Papilio: is an association that supports refugees to find a psychotherapist and help to refund an interpreter if needed, it’s for refugees of every age.
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Consultation Psychothérapeutique pour Migrants (CPM): also, an association, but it offers psychotherapeutic or psychiatric support for refugees with psychiatric diagnoses especially for children and teenagers. It can be single psychotherapy, group therapy or family and/or couple therapy, it takes place outside the refugee facilities and can be reimbursed by the health insurances, usually consisting of 10 psychotherapy sessions.
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PM as part of the project STRENGTHS: developed by WHO, laypersons are trained for 8 days to help refugees to cope better with stress and problems, to activate them and to strengthen their social support, until now only single therapy settings for children and teenagers outside the refugee facilities took place 6 times for 90 minutes, group therapy is also planned.
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Digital psychological support for refugees is a guided App for self-help for adults, developed by the Swiss Red Cross and the University Berne, giving useful information about the Swiss health system and provides psychoeducation, exercises, and tips for the management of stress, problems, sleep, daily structure, chronic pain.
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ComPaxion: is an easy access transcultural psychological consulting programme in the mother tongue of the refugees offered by a private association, it’s not a psychotherapy, but provides psycho-education and activation of resources, doesn’t deal with severe psychiatric diagnoses, but can help to discover them and to find a psychiatrist or psychotherapist to deal with it, with single or group setting with 5 to 10 sessions once a week or even more for 60 minutes outside the refugee facilities or online.
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START (Stress-Traumasymptoms-Arousal-Regulation-Treatment): is an awareness-based programme with relaxing and stimulating exercises and psycho-educational trainings, offered in group setting for accompanied or unaccompanied children and teenagers with traumas caused by their migration experiences, taking place outside or inside the refugee facilities once a week for 150 minutes usually 10 times.
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PsyAsyl: is an association that has organized a network of psychotherapist and psychiatrists who offer mostly free sessions for teenagers and adults, taking place in their practice with 15 hours at the most, frequency and intensity are not regulated.
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Femmes-Tables and Men-Tables is an easy access programme offering moderated discussions about health, family and integration with peers often also with refugee experiences, taking place inside or outside the refugee facilities and lasting 2 hours with a varying frequency.
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Brückenbauer*innen (bridge builder): are already integrated refugees helping traumatized refugees to deal with their everyday lives, supporting their self-efficacy and minimise their stress.
24/06/2021
COVID-19 has reinforced deficits in psychotherapeutic care in the EU
NPCE Event 2021
The Network for Psychotherapeutic Care in Europe (NPCE) discussed the challenges and implications for psychotherapeutic care during the COVID-19 pandemic. The event was hosted by Dr Nikolaus Melcop, Vice President of the BPtK, and Dr Jorge Gravanita, President of the Portuguese Society for Clinical Psychology (SPPC), and took place on 24 June 2021. Given the Portuguese EU Council Presidency, a focus was laid on Portugal and possible spill-over effects of the national mental health reform plans.After one and a half year living with the pandemic, it becomes more and more evident that the pandemic also affects mental health. It is well known from psychotherapy research, that the longer a crisis, a conflict, and a life-threatening event lasts, the more likely it is that the psychological resistance and regeneration will be overwhelmed and result in mental disorders. Existential fears, work at home, closed schools, the fear of infection, illness or even the loss of family members, but also the overwhelming situation for healthcare professionals in hospitals can endanger mental health. However little has been done at the EU level to address this issue. The European Commission aims at building a European Health Union which should allow a better and common response to a crisis and should ensure access to vaccination or face masks. This is important, for sure. But it neglects the psychological burden of the pandemic to the European societies. With an initiative, the NPCE has pointed out that the European Centre for Disease Control and Prevention (ECDC) should analyse and identify mental health issues due to COVID-19 with the aim that national health systems can respond to emerging risks or a higher need in treatment. This has been supported by Members of the European Parliament and has been introduced to the on-going parliamentary negotiations. However, the EU needs to do more. Health in all policies is a well-known maxim, however Mental Health in All Policies must be underlined.
Case study Portugal
An ad-hoc study on the social effects of the pandemic in Portugal revealed that children and young people, students, but also older people, low-income families, as well as women and single mothers are particularly suffering from the COVID-19 pandemic. Dr Rita Gouveia, post-doc researcher in sociology with a focus on families from the Institute of Social Sciences of the University of Lisbon, supervised the multidisciplinary survey and presented the result. The survey revealed a narrative of fatigue. While mental health was considered an issue, it became a present issue during the confinement. Anxiety, insomnia, unhappiness, the feeling of isolation, emotional draining, and issues to manage emotions and a lack of privacy were reported. Besides this, the survey revealed a correlation between the political trust in decision makers and the acceptance of confinement measures: the less the trust, the less political measures were accepted.Dr Isabel Prata, Intervention Service in Additive Behaviours and Dependencies (SICAD) & SPPC Vice-President, reported that helplines were often contacted to receive psychotherapeutic care since services were not available during the pandemic. During the confinement or when the feeling of loneliness was strong, the inquiries increased. With regards to addiction disorders, for those who already showed problematic consumer behaviour before the pandemic, the behaviour was reinforced during the lockdown measures. Among the elderly, gambling in form of scratch cards was observed. Also, prevention services in schools and on the streets had to be paused. In her view, a higher demand for psychotherapeutic care will very soon be noticeable.
Dr Miguel Xavier, Director of the National Mental Health Program in Portugal, reported that even before the pandemic, psychotherapeutic care was not adequately secured since there was a lack of capacities and funding. Also, it is worrying that the numbers of healthcare professionals, psychotherapists included, in Portugal has not been increased over the last 10 years resulting in a shortage of care givers that impacts the provision of care. In his view, the mental health challenges due to the COVID-19 pandemic need to be tackled with a holistic public health approach. “Mental Health in All Policies” must be taken in account in all measures. For example, health promotion, prevention, digital solutions, risk group-specific measures, but also the number of psychotherapists should be strengthened. Portugal had in the past contributed to strengthening mental health at EU level, but the implementation of existing recommendations for action in the Member States was deficient.
Jeopardized access to psychotherapeutic care
That the demand for psychotherapeutic care has been risen, but at the same time access to psychotherapy was not always given, was noticed in other countries as well.
In Italy, too few psychotherapists are involved in public care. This leads to the fact that the patients suffer unnecessarily long. About three quarters of the people who need psychotherapy are not granted access. Those who urgently need support have the worst access to psychotherapy and cannot always afford it. In addition, patients would be prescribed medication too quickly, even though they actually needed psychotherapeutic care. Although the Italian government is working to increase the number of psychotherapists in the public health system, implementation will take time. In order to cover the increased need for care, some private psychotherapy schools offer inexpensive care to bridge the gap. At the same time, this would have the advantage that the psychotherapists in training could gain practical experience. Besides this, a focus should be placed on the rehabilitation of people with mental illnesses.
In Germany, the psychological stress caused by the pandemic has increased. Children and young people suffer particularly from the measures taken to combat the pandemic. Children from low-income families were also more at risk than children from wealthy families. The demand for psychotherapeutic treatment is increasing and exacerbating the existing problem of a lack of therapy places: The psychotherapy practices received 40 percent more inquiries, the demand in child and adolescent psychotherapy practices rose by 60 percent. Psychotherapy via video is not suitable for all patients, but still, it could allow to provide psychotherapy during the pandemic for some patients. Fortunately, people with mental illnesses and psychotherapists were given priority access to the COVID-19 vaccination. Nonetheless, concrete policy measures to strengthen mental health and psychotherapeutic care that solve existing care problems remain overdue.
Call for Action
So far, the EU has not considered the psychological stress caused by the pandemic in its measures, although mental illness was the third most common cause of illness in Europe before the COVID-19 pandemic. The NPCE has therefore adopted a position paper in which it calls on the EU and the Member States to act together: Data on the psychological consequences of the pandemic must be improved to develop European recommendations for mental health promotion, prevention and care, which Member States should implement, but also support the access to psychotherapeutic care in Europe.
Reports from other countries
Hungary
By Máté Kapitány-Fövény
As part of an international online study of the Mental Health Sector of the Scientific Research Institute of the Pan-Hellenic Medical Association, the Hungarian research team assessed 738 adults (both healthy controls and respondents with mental disorders) during the pandemic (between 30.06.2020-12.09.2020), and reported especially severe anxiety and depression symptoms, increased smoking and increased use of sedatives among mental disorder patients as well as a significant reduction in physical activity within this time interval among the same subgroup as compared to healthy controls. In May 2020, a research group of the University of Szeged assessed a non-representative sample of Hungarian adults in the time of the national quarantine situation (n= 431). 34.1% of the respondents showed depression symptoms, while 36.2% were characterized by elevated levels of anxiety. Between 4th March and 25 May 2020 (during lockdown) Eötvös Loránd University launched a specialist online counselling program to provide crisis mental health support for all university members. The program consisted of one to three sessions (altogether 47 clients received this support). According to the observations of the counsellors involved in this program, the clients main psychological problems encompassed the fear from the virus, anxiety, fatigue, addictive behaviours and symptoms of depression or psychosis. Three key features of online counselling were identified: 1) the need of a problem-oriented approach; 2) the challenges of building rapport online; 3) the frames of online counselling and the difficulty of controlling them. Similar online programs were implemented in many other locations/institutes. An online Pro Bono Counselling Project was provided by many Hungarian psychologist during the lockdown (Spring, 2020) to reach those clients in need who otherwise could not afford psychotherapy or counselling. As a response to the public health concern regarding post-Covid syndrome, a special outpatient clinic was opened (2th of April 2021) in the National Institute of Mental Health, Neurology and Neurosurgery (Budapest, Hungary) which is currently one of Hungary’s main psychiatric centres. The primary goal of this clinic is to provide help for those clients who struggle with the mental symptoms of post-Covid syndrome. The Hungarian Psychiatric Association has recently held its XXIV. itinery congress focusing on the major mental health correlates of peri and post Covid situation and condition, including both the individual (e.g. psychiatric symptoms of patients and health care workers, neuropsychiatric characteristics of post-covid syndrome, etc) and the organizational (e.g. cutting the availability of inpatient psychiatric beds, redeployment experiences) levels. The Hungarian Academy of Sciences – as requested by the Hungarian Government - has started to develop a post Covid strategy in the Spring of 2021, alongside with working on a medium-term national pandemic plan.
Switzerland
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 Department for Health (BAG) which is part of the Federal Department 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 months 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.
24/06/2021
Digital Applications in Psychotherapy and Developments in the Corona Crisis
Goals for further professionalisation of psychological psychotherapists in Europe
International video conference on 29 September 2020
The corona pandemic and the measures associated with it have an impact on the psyche of all people. The pandemic has brought about extreme changes in the working and living situation for large sections of the population, with associated stress levels and insecurity. The work situation for psychotherapists in particular has also changed drastically, especially during the period of the lockdown. In the corona crisis, psychotherapists have a special responsibility for the care of mentally ill or strained people.
This was the general tenor of the international video conference "Digital Health Apps in consideration of the corona crisis as well as developments and aims for further professionalization of the psychological psychotherapists in member countries", held by the German Chamber of Psychotherapists (BPtK) in cooperation with the members of the Network for Psychotherapeutic Care in Europe (NPCE) on 29 September 2020. The event was attended by Nikolaus Melcop, Vice President of the BPtK, and by experts from the NPCE from Austria, Cyprus, Hungary, Ireland, Italy, Lithuania, Poland, Portugal, Romania, Switzerland and the United Kingdom. Since 2011, clinical psychologists and psychological psychotherapists from 20 European countries have been in regular contact via the NPCE to exchange information on the care situation of mentally ill people. They also discussed ways to improve care and to further develop the profession in their countries.
During the video conference on 29 September 2020, the focus of the first round of discussion was on the status and framework conditions of internet-based interventions such as health apps, digital treatment programmes and video consultation in the work of the psychotherapist.
How has Corona changed therapy?
It became clear that the corona pandemic has accelerated the spread of digital applications and video-based psychotherapy. The development of digital structures is now taking place everywhere, but usually only a few individual models have been implemented, e.g. for specific target groups. They are not yet part of a catalogue of services financed by statutory health insurance.
There was consensus among the participants that digital applications are effective for certain target groups while they cannot replace the psychotherapeutic session in direct personal contact and should not be used without professional guidance. It is not a question of either/or, but rather of the correct use of digital media on a case-by-case basis and the supplementation of established therapies with new digital possibilities.
Overall, corona has increased public awareness of the importance of mental health and psychotherapy as an effective and helpful intervention. The crisis triggered by corona is thus also an opportunity to make more visible the contribution that psychotherapists can make to keeping people healthy. This was the conclusion of the participants.
Expert panel
Cyprus (Ph.D Maria Karekla)
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At the beginning, Maria Karekla from the University of Cyprus presented the results of a Europe-wide survey on changes in everyday psychotherapeutic work during the corona crisis. 8858 psychologists and psychotherapists from all over Europe were included in the survey. 82 percent of them already used digital therapy components or intended to do so in the near future. For 66 percent of them it was the first time. Karekla pointed to the problems involved: only 9 percent of respondents had received prior instruction and (free) internet access for those seeking advice and the privacy of treatment was not always guaranteed. Moreover, remuneration was often not regulated. In her home country Cyprus itself, the problems are still considerable. On the other hand, there are positive effects. Feedback from clients indicated that the video consultation is considered to be comparably effective. As a result of the study, recommendations were formulated for psychotherapists, for health services, supervisory authorities and for app developers.
Lithuania (Elena Gaudiesiute)
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In Lithuania, the country‘s more than 100 public mental health centres provide assistance even in times of corona. Since the beginning of the year, free psychotherapeutic sessions have been part of the public health services. As a result of corona, the number of people seeking advice in face-to-face contact has decreased, while a newly established hotline was used by thousands. Elena Gaudiesiute underlined that the development of internet-based interventions is making good progress in Lithuania. There are many good initiatives, but the effectiveness of the various apps used to address mental health problems needs to be evaluated more and in a scientific manner. Overall, the care situation of mentally ill people was still problematic, with only 1 percent of health care expenditure being spent on medical health centres offering psychotherapeutic services.
Portugal (Rosa Castro André and Dr Jorge Gravanita)
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The internet expert Rosa Castro André, psychotherapist at the NOVA University in Lisbon, presented the project she developed, an internet-based hotline. It is currently being tested as a prototype and also contains a special tool for Covid 19 cases. Although a hotline run by the national health service already exists, this platform is too cumbersome, said Rosa Castro André. The new platform was developed in exchange with users, students and psychologists and incorporated their experiences and expectations. It was a challenge to make also dynamic psychotherapy and cognitive behavioural therapy digitally accessible. She stressed that digital applications are neither more nor less effective than a personal psychotherapeutic session but work in a different way.
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Dr Jorge Gravanita, President of the Portuguese Association of Clinical Psychologists (SPPC), complained about the largely lacking political regulatory framework for psychotherapy in his country: no binding regulations for health apps, no definition of psychotherapy and no reimbursement for psychotherapeutic services in the public health system exist, unless when prescibed by a psychiatrist. Psychotherapists still had too weak a voice in health policy, both at the national and the European level.
Ireland (Vasilis S. Vasiliou)
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Vasilis S. Vasileiou, a researcher at University College Cork (UCC), underlined the importance of targeting aid in times of corona such as students at higher institutions who are using illicit drugs. He presented the MyUSE app, which he co-developed and evaluated at University College Cork (UCC), Ireland, and which is intended to enable people to deal with illicit drug use, but can also be used for other mental health platforms. He showed how personalised feedback based on the risk level of the user can be employed to interactively develop individual goals and customised risk reduction activities as well as to support the implementation of risk-avoiding behavioural strategies. According to Vasilis S. Vasileiou, a central challenge is data management and the prevention of abuse.
Germany (Dr phil Nikolaus Melcop)
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For Germany, BPtK Vice President Melcop related that since October 2019, psychotherapeutic counselling in the form of video consultation has been remunerated to a certain extent by the statutory health insurance companies. Only software certified in terms of data security and protection of privacy may be used. In principle, 20 percent of consultations can be carried out via video; due to corona, this restriction has been temporarily lifted. Health apps are now being tested by the competent authority, the Federal Institute for Drugs and Medical Devices (BfArM), and a list of them are made publicly available. These certified apps may then be prescribed by psychotherapists. The BPtK demands that apps are only used after an indication has been given and with the assistance of psychotherapists or doctors. The costs are covered by the statutory health insurance.
Hungary (written report by Máté Kapitány-Fövény)
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In Hungary, during the first wave of the COVID 19 pandemic, the quarantine regulations allowed for Skype counselling by listed psychotherapists. Máté Kapitány-Fövény of Semmelweis University in Budapest, also clinical psychologist at NyírőGyula National Institute of Psychiatry and Addictions, underlines in his report the effectiveness of combining self-management interventions and therapeutic guidance. E-health interventions offer useful but limited possibilities; severe mental disorders should be treated in personal psychotherapy and only digital health apps based on effectiveness studies should be used. In Hungary, both programmes developed in international cooperation and nationally developed e-health tools are available. The latter are now to be specifically promoted within the framework of a call for proposals by the Hungarian Ministry of Research.
Romania (written report by Roman Viorel)
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The Covid 19 pandemic has shown that e-health interventions are accepted. Many psychologists continued online consultations even after the relaxation of corona measures, although personal therapy was allowed again. Roman Viorel, who has been working with the Alliance for the Fight against Alcoholism and Drug Abuse (ALIAT) since 2002, which offers online counselling and a self-help app, underlines in his report the advantage of greater confidentiality of online psychotherapy. People in Romania are less anxious online than if they had to go to psychiatric institutions for help. However, Romania is not yet sufficiently prepared for digital interventions, there are no guidelines and no professional standards. The biggest obstacle is the lack of funding.
Poland (Iga Jaracewska)
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Iga Jaracewska, who is a trainer at the Polish "Motivational Interviewing Network of Trainers", explained the situation in Poland. Corona opened up new possibilities, and efficient and effective online treatment tools, e.g. for anxiety disorders, have been developed very quickly. Jaracewska underlined „online tools are useful, complementary instruments in therapy, they can shorten waiting times and are also accepted by clients. However, the most important part of any therapy is the quality of the relationship. The personal face-to-face conversation must remain ensured.“ The fact that people were offered help quickly and free of charge out of solidarity on the part of the therapists greatly enhanced the reputation of psychotherapy in Poland.
Austria (Karin Kalteis)
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Karin Kalteis from the board of the Association of Austrian Psychologists (BÖP) reported that so far only a small part of psychotherapists in Austria uses digital health apps. At university level, some research projects are underway, but there are no official guidelines for the use of apps. Online counselling is possible in Austria on a case-by-case basis and is permitted to an unlimited extent until the end of the year, possibly longer, due to corona. A special competence in online counselling is required. Covid 19 has increased client acceptance of treatment via digital media. The statutory health insurances accept its use. It would be important to develop guidelines for psychotherapy via digital media.
Switzerland (Veronica Isabel Defièbre)
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Surprisingly unaffected by Covid 19, psychotherapy in Switzerland is still going on, reports Veronica Isabel Defièbre of the board of the Association of Swiss Psychotherapists (ASP). There are no regulations for internet-based forms of psychotherapy and the health authorities see no need to adapt the law governing the psychological professions. Video consultations remain prohibited, and in the wake of the pandemic, only limited and temporary telephone counselling was made possible. Apps are not planned. However, discrepancies between the official policy, the actual counselling situation and the remuneration situation probably exist. The health insurance companies are in the process of developing their own apps in cooperation with colleges and universities, e.g. for depression and anxiety disorders. Many patients would also like to have means of communication other than personal sessions, but generally prefer personal sessions to virtual forms of counselling, Defièbre says.
Procedures and quality standards differ greatly in the various countries
The reports show that the challenges in developing digital interventions and dealing with the negative effects of the pandemic are similar everywhere. There are many examples of good practice. However, there are hardly any established structures to deal with the psychological consequences of corona. Digital applications are mainly developed by each country itself. The quality requirements are very different. They range from regulatory testing to the absence of any specifications.
According to the unanimous opinion of those involved, the prerequisites for safe and effective treatment are evidence-based programmes and applications tested for effectiveness, as well as training in their use. The effects of digital applications on the cooperation between therapist and client also need to be further investigated. Digital applications cannot replace psychotherapy in personal contact. Almost everywhere, political framework conditions with regard to quality assurance and cost coverage still lag behind the technical possibilities and also practical experiences with digital applications.
Need for action both at the national and the European level
The participants regretted that in the first phase of dealing with corona, negative psychological consequences – e.g. the isolation of older people – were not sufficiently taken into account and that incomplete health policy decisions were made as a result.
Although the perception of the importance of mental health had increased, this was not yet sufficiently reflected in political action. The access of vulnerable groups to psychotherapy must be further improved. The mental health consequences of Covid 19 should be better integrated into policies at national and European level. The network intends to work towards this goal under the upcoming Portuguese EU Council Presidency in the first half of 2021.
Professional profile of the psychological psychotherapist remains heterogeneous in Europe
The second part of the conference focused on current developments in vocational policy. The contributions of the participants showed a still very heterogeneous picture of the training, definition and rights of psychological psychotherapists in the individual European countries. The spectrum ranges from a largely lacking regulation of the professional profile, insufficient cost coverage, a lack of postgraduate internship possibilities and insufficient employment opportunities for psychotherapists in the public health system, as in Cyprus, Lithuania, Poland and Portugal, to countries with detailed statutory rights, obligations and further training regulations.
Examples of good practice from other countries could be helpful for the development in their own country, the participants said. The training system in the United Kingdom and the reform of vocational training in Germany, which came into force on 1 September, played a major role in the discussion.
In future, the structure of studies and further training for psychotherapists in Germany will be comparable to that of the medical profession, explained Nikolaus Melcop in his presentation. The training will then include a Master's degree with intensive practical and scientific qualification, a final state examination and state certification for self-employed work as a psychotherapist. The course will be followed by further training, which concludes with the professional title "Specialised psychotherapist for children and adolescents“ or "Specialised psychotherapist for adults“. This further training entitles the holder to set up a private practice within the outpatient system of the statutory health insurance. The further training will be completed in employment with appropriate remuneration.
For the United Kingdom, Lee Hogan, ((Foto einfügen)) clinical psychologist with the NHS and Assessment Director for the North Wales Clinical Psychology Programme at Bangor University, gave a detailed insight into the system of psychotherapeutic training, which is uniformly structured by the British Psychological Society (BPS), the professional association of psychologists, and closely linked to the National Health Service (NHS). This ensures various training places, remuneration within the framework of the training for three years and a scientific basis for the training through a research project in the final phase of the training. Lee Hogan emphasised the importance of inter-professional cooperation between nurses, doctors, psychiatrists and psychotherapists in the care of mentally ill people, which is well-established in the United Kingdom.
In Ireland, training structures are similar, but there is currently no professional register. However, Vasilis Vasileiou reported that a committee to deal with this issue will be set up in 2021.
In Switzerland, a revision and limitation of the legally recognised methods is currently being discussed. According to the notions of psychotherapists and also of the statutory health insurance companies, the delegation system still in force should be replaced by a prescription system. But there is still no agreement to grant psychotherapists more extensive independent rights, says Veronika Defièbre. The Swiss Federal Council could make a decision this year.
In Hungary, since February 2020, the penal code has stipulated a one-year prison sentence for those who provide psychotherapy without qualifications in the health care system. Only clinical psychologists - with and without psychotherapeutic training - are thus permitted to provide treatment.
In the case of Italy, Alberto Zucconi, ((Foto einfügen)) President of the Centered Approach Institute IACP, made the critical comment that university training is too remote from professional practice and that the procedure for recognition of training centres is too bureaucratic. Since 1998, the profession of psychologist and the training of psychotherapists have been regulated by law in Italy - around 40 percent of the 160,000 psychologists in Italy have been trained in psychotherapy - and the professional legislation provides for a chamber of psychologists. According to Alberto Zucconi, professional representation must focus more on the rights and interests of patients.
In Austria, a legal revision of the professional law has been discussed for years. The multitude of approved treatment methods is to be limited, but so far without result.
The exchange between the experts showed that - while the framework conditions for the profession of psychotherapists in Europe are very different in terms of organisational form, competences, rights and remuneration and the access of patients to psychotherapy is still often completely insufficient - psychotherapy is nevertheless well on the way to establishing itself at a high professional and scientific level everywhere in Europe. A next step could be to define uniformly the basic professional skills required to provide psychotherapy, regardless of the professional title.
In conclusion, all participants agreed that the NPCE network could continuously make an important contribution to improving the provision of psychotherapy for mentally ill people in the health systems of the various European countries and thus also at EU level.
Downloads
Country report Portugal NPCE 29 Sept.pdf
Download
Kick-off speech Dr Nicolaus Melcop
Biographies of the experts
Country reports and presentations
Cyprus (Ph.D Maria Karekla)
At the beginning, Maria Karekla from the University of Cyprus presented the results of a Europe-wide survey on changes in everyday psychotherapeutic work during the corona crisis. 8858 psychologists and psychotherapists from all over Europe were included in the survey. 82 percent of them already used digital therapy components or intended to do so in the near future. For 66 percent of them it was the first time. Karekla pointed to the problems involved: only 9 percent of respondents had received prior instruction and (free) internet access for those seeking advice and the privacy of treatment was not always guaranteed. Moreover, remuneration was often not regulated. In her home country Cyprus itself, the problems are still considerable. On the other hand, there are positive effects. Feedback from clients indicated that the video consultation is considered to be comparably effective. As a result of the study, recommendations were formulated for psychotherapists, for health services, supervisory authorities and for app developers.
Lithuania (Elena Gaudiesiute)
In Lithuania, the country‘s more than 100 public mental health centres provide assistance even in times of corona. Since the beginning of the year, free psychotherapeutic sessions have been part of the public health services. As a result of corona, the number of people seeking advice in face-to-face contact has decreased, while a newly established hotline was used by thousands. Elena Gaudiesiute underlined that the development of internet-based interventions is making good progress in Lithuania. There are many good initiatives, but the effectiveness of the various apps used to address mental health problems needs to be evaluated more and in a scientific manner. Overall, the care situation of mentally ill people was still problematic, with only 1 percent of health care expenditure being spent on medical health centres offering psychotherapeutic services.
Portugal (Rosa Castro André and Dr Jorge Gravanita)
The internet expert Rosa Castro André, psychotherapist at the NOVA University in Lisbon, presented the project she developed, an internet-based hotline. It is currently being tested as a prototype and also contains a special tool for Covid 19 cases. Although a hotline run by the national health service already exists, this platform is too cumbersome, said Rosa Castro André. The new platform was developed in exchange with users, students and psychologists and incorporated their experiences and expectations. It was a challenge to make also dynamic psychotherapy and cognitive behavioural therapy digitally accessible. She stressed that digital applications are neither more nor less effective than a personal psychotherapeutic session but work in a different way.
Dr Jorge Gravanita, President of the Portuguese Association of Clinical Psychologists (SPPC), complained about the largely lacking political regulatory framework for psychotherapy in his country: no binding regulations for health apps, no definition of psychotherapy and no reimbursement for psychotherapeutic services in the public health system exist, unless when prescibed by a psychiatrist. Psychotherapists still had too weak a voice in health policy, both at the national and the European level.
Ireland (Vasilis S. Vasiliou)
Vasilis S. Vasileiou, a researcher at University College Cork (UCC), underlined the importance of targeting aid in times of corona such as students at higher institutions who are using illicit drugs. He presented the MyUSE app, which he co-developed and evaluated at University College Cork (UCC), Ireland, and which is intended to enable people to deal with illicit drug use, but can also be used for other mental health platforms. He showed how personalised feedback based on the risk level of the user can be employed to interactively develop individual goals and customised risk reduction activities as well as to support the implementation of risk-avoiding behavioural strategies. According to Vasilis S. Vasileiou, a central challenge is data management and the prevention of abuse.
Germany (Dr phil Nikolaus Melcop)
For Germany, BPtK Vice President Melcop related that since October 2019, psychotherapeutic counselling in the form of video consultation has been remunerated to a certain extent by the statutory health insurance companies. Only software certified in terms of data security and protection of privacy may be used. In principle, 20 percent of consultations can be carried out via video; due to corona, this restriction has been temporarily lifted. Health apps are now being tested by the competent authority, the Federal Institute for Drugs and Medical Devices (BfArM), and a list of them are made publicly available. These certified apps may then be prescribed by psychotherapists. The BPtK demands that apps are only used after an indication has been given and with the assistance of psychotherapists or doctors. The costs are covered by the statutory health insurance.
Hungary (written report by Máté Kapitány-Fövény)
In Hungary, during the first wave of the COVID 19 pandemic, the quarantine regulations allowed for Skype counselling by listed psychotherapists. Máté Kapitány-Fövény of Semmelweis University in Budapest, also clinical psychologist at NyírőGyula National Institute of Psychiatry and Addictions, underlines in his report the effectiveness of combining self-management interventions and therapeutic guidance. E-health interventions offer useful but limited possibilities; severe mental disorders should be treated in personal psychotherapy and only digital health apps based on effectiveness studies should be used. In Hungary, both programmes developed in international cooperation and nationally developed e-health tools are available. The latter are now to be specifically promoted within the framework of a call for proposals by the Hungarian Ministry of Research.
Romania (written report by Roman Viorel)
The Covid 19 pandemic has shown that e-health interventions are accepted. Many psychologists continued online consultations even after the relaxation of corona measures, although personal therapy was allowed again. Roman Viorel, who has been working with the Alliance for the Fight against Alcoholism and Drug Abuse (ALIAT) since 2002, which offers online counselling and a self-help app, underlines in his report the advantage of greater confidentiality of online psychotherapy. People in Romania are less anxious online than if they had to go to psychiatric institutions for help. However, Romania is not yet sufficiently prepared for digital interventions, there are no guidelines and no professional standards. The biggest obstacle is the lack of funding.
Poland (Iga Jaracewska)
Iga Jaracewska, who is a trainer at the Polish "Motivational Interviewing Network of Trainers", explained the situation in Poland. Corona opened up new possibilities, and efficient and effective online treatment tools, e.g. for anxiety disorders, have been developed very quickly. Jaracewska underlined „online tools are useful, complementary instruments in therapy, they can shorten waiting times and are also accepted by clients. However, the most important part of any therapy is the quality of the relationship. The personal face-to-face conversation must remain ensured.“ The fact that people were offered help quickly and free of charge out of solidarity on the part of the therapists greatly enhanced the reputation of psychotherapy in Poland.
Austria (Karin Kalteis)
Karin Kalteis from the board of the Association of Austrian Psychologists (BÖP) reported that so far only a small part of psychotherapists in Austria uses digital health apps. At university level, some research projects are underway, but there are no official guidelines for the use of apps. Online counselling is possible in Austria on a case-by-case basis and is permitted to an unlimited extent until the end of the year, possibly longer, due to corona. A special competence in online counselling is required. Covid 19 has increased client acceptance of treatment via digital media. The statutory health insurances accept its use. It would be important to develop guidelines for psychotherapy via digital media.
Switzerland (Veronica Isabel Defièbre)
Surprisingly unaffected by Covid 19, psychotherapy in Switzerland is still going on, reports Veronica Isabel Defièbre of the board of the Association of Swiss Psychotherapists (ASP). There are no regulations for internet-based forms of psychotherapy and the health authorities see no need to adapt the law governing the psychological professions. Video consultations remain prohibited, and in the wake of the pandemic, only limited and temporary telephone counselling was made possible. Apps are not planned. However, discrepancies between the official policy, the actual counselling situation and the remuneration situation probably exist. The health insurance companies are in the process of developing their own apps in cooperation with colleges and universities, e.g. for depression and anxiety disorders. Many patients would also like to have means of communication other than personal sessions, but generally prefer personal sessions to virtual forms of counselling, Defièbre says.
Procedures and quality standards differ greatly in the various countries
The reports show that the challenges in developing digital interventions and dealing with the negative effects of the pandemic are similar everywhere. There are many examples of good practice. However, there are hardly any established structures to deal with the psychological consequences of corona. Digital applications are mainly developed by each country itself. The quality requirements are very different. They range from regulatory testing to the absence of any specifications.
According to the unanimous opinion of those involved, the prerequisites for safe and effective treatment are evidence-based programmes and applications tested for effectiveness, as well as training in their use. The effects of digital applications on the cooperation between therapist and client also need to be further investigated. Digital applications cannot replace psychotherapy in personal contact. Almost everywhere, political framework conditions with regard to quality assurance and cost coverage still lag behind the technical possibilities and also practical experiences with digital applications.
Need for action both at the national and the European level
The participants regretted that in the first phase of dealing with corona, negative psychological consequences – e.g. the isolation of older people – were not sufficiently taken into account and that incomplete health policy decisions were made as a result.
Although the perception of the importance of mental health had increased, this was not yet sufficiently reflected in political action. The access of vulnerable groups to psychotherapy must be further improved. The mental health consequences of Covid 19 should be better integrated into policies at national and European level. The network intends to work towards this goal under the upcoming Portuguese EU Council Presidency in the first half of 2021.
Professional profile of the psychological psychotherapist remains heterogeneous in Europe
The second part of the conference focused on current developments in vocational policy. The contributions of the participants showed a still very heterogeneous picture of the training, definition and rights of psychological psychotherapists in the individual European countries. The spectrum ranges from a largely lacking regulation of the professional profile, insufficient cost coverage, a lack of postgraduate internship possibilities and insufficient employment opportunities for psychotherapists in the public health system, as in Cyprus, Lithuania, Poland and Portugal, to countries with detailed statutory rights, obligations and further training regulations.
Examples of good practice from other countries could be helpful for the development in their own country, the participants said. The training system in the United Kingdom and the reform of vocational training in Germany, which came into force on 1 September, played a major role in the discussion.
In future, the structure of studies and further training for psychotherapists in Germany will be comparable to that of the medical profession, explained Nikolaus Melcop in his presentation. The training will then include a Master's degree with intensive practical and scientific qualification, a final state examination and state certification for self-employed work as a psychotherapist. The course will be followed by further training, which concludes with the professional title "Specialised psychotherapist for children and adolescents“ or "Specialised psychotherapist for adults“. This further training entitles the holder to set up a private practice within the outpatient system of the statutory health insurance. The further training will be completed in employment with appropriate remuneration.
For the United Kingdom, Lee Hogan, ((Foto einfügen)) clinical psychologist with the NHS and Assessment Director for the North Wales Clinical Psychology Programme at Bangor University, gave a detailed insight into the system of psychotherapeutic training, which is uniformly structured by the British Psychological Society (BPS), the professional association of psychologists, and closely linked to the National Health Service (NHS). This ensures various training places, remuneration within the framework of the training for three years and a scientific basis for the training through a research project in the final phase of the training. Lee Hogan emphasised the importance of inter-professional cooperation between nurses, doctors, psychiatrists and psychotherapists in the care of mentally ill people, which is well-established in the United Kingdom.
In Ireland, training structures are similar, but there is currently no professional register. However, Vasilis Vasileiou reported that a committee to deal with this issue will be set up in 2021.
In Switzerland, a revision and limitation of the legally recognised methods is currently being discussed. According to the notions of psychotherapists and also of the statutory health insurance companies, the delegation system still in force should be replaced by a prescription system. But there is still no agreement to grant psychotherapists more extensive independent rights, says Veronika Defièbre. The Swiss Federal Council could make a decision this year.
In Hungary, since February 2020, the penal code has stipulated a one-year prison sentence for those who provide psychotherapy without qualifications in the health care system. Only clinical psychologists - with and without psychotherapeutic training - are thus permitted to provide treatment.
In the case of Italy, Alberto Zucconi, ((Foto einfügen)) President of the Centered Approach Institute IACP, made the critical comment that university training is too remote from professional practice and that the procedure for recognition of training centres is too bureaucratic. Since 1998, the profession of psychologist and the training of psychotherapists have been regulated by law in Italy - around 40 percent of the 160,000 psychologists in Italy have been trained in psychotherapy - and the professional legislation provides for a chamber of psychologists. According to Alberto Zucconi, professional representation must focus more on the rights and interests of patients.
In Austria, a legal revision of the professional law has been discussed for years. The multitude of approved treatment methods is to be limited, but so far without result.
The exchange between the experts showed that - while the framework conditions for the profession of psychotherapists in Europe are very different in terms of organisational form, competences, rights and remuneration and the access of patients to psychotherapy is still often completely insufficient - psychotherapy is nevertheless well on the way to establishing itself at a high professional and scientific level everywhere in Europe. A next step could be to define uniformly the basic professional skills required to provide psychotherapy, regardless of the professional title.
In conclusion, all participants agreed that the NPCE network could continuously make an important contribution to improving the provision of psychotherapy for mentally ill people in the health systems of the various European countries and thus also at EU level.
Downloads
Country report Portugal NPCE 29 Sept.pdf
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Kick-off speech Dr Nicolaus Melcop
Biographies of the experts
Country reports and presentations