In recent years, health insurance companies have observed a dramatic increase in sick leave due to depression, burn-out and bullying. The most important cause must be seen as the increasingly high pressure to perform in the world of work and an increasing (subjective) threat of job loss, social decline and poverty. Divorce and loneliness in old age reinforce this burdening factor. Continued unemployment or termination through no fault of one's own can cause anxiety or depression. This experienced pressure leads to aggressive interaction, mistrust, intolerance and often bullying.
These problems have become so serious that larger industrial companies and public institutions have found it necessary to set up special advice centres for their employees. Psychotherapy can only be of little help here, because the therapists are not trained to advise on social and legal problems. Unemployment, general fear of job losses and economic downturns can put a strain on people. Social problems may contribute to an outbreak of depressive or anxiety-related disorder.
For psychotherapy it is of vital importance what part the internal psychological factors of the affected person play in this. This is not always easy to judge. One must also ask oneself whether, within the temporal and economic framework in which psychotherapy takes place, results can be achieved with justifiable effort that justify its use.
In this context, it is important to address the problem of the concept of disease in psychotherapy. The average citizen who grew up in our welfare state assumes that whenever he feels ill he can expect fast and competent help free of charge.
While this still applies with increasing restrictions in the area of somatic health care, the legislator has defined several restrictions for psychotherapy, which have been described in detail in the so-called psychotherapy guidelines. It stated that the question of the need for treatment of psychotherapy with psychotherapy depends on the fact that the treatment (which is then to be paid for by the health insurance companies) may only serve the treatment of a disease which is based on psychological and psychological causes.
This may make sense at first glance, but also involves a number of problems.
How should we deal with those people who are experiencing psychological difficulties due to the above-mentioned social problems?
Are they ill within the meaning of the directives or do they have "regular" social problems?
How should we assess the fact that people with psychological problems (alcoholism, depression, personality disorders, etc.) are much more frequently confronted with social and economic problems?
All these questions are still open and are being intensively discussed by experts.
It is obvious that the willingness of society to spend money on the treatment of such problems is very closely related to the general economic situation.
Psychotherapy, which is to be paid for by both public and private health insurance, is subject to approval. This means that all treatments must be approved by the health insurance companies before they are carried out. For this purpose, the so-called expert procedure is carried out. The treating therapist must submit a report with treatment plan, diagnosis, prognosis and therapy goals to the health insurance company. This anonymized report is evaluated by an external expert, also an experienced psychotherapist.
This procedure is also discussed very intensively in expert circles (for reference see e.g. Koehlke, 2000, in German) and is highly controversial.