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)

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.


Country report Portugal NPCE 29 Sept.pdf

Kick-off speech Dr Nicolaus Melcop

Biographies of the experts

Country reports and presentations