Struggling with your mental health? You need therapy in English, and fast! But in the German capital, bureaucracy might get in your way.
Walk into any faux-shabby candlelit bar in the city, pull up a mismatched chair and ask the group of English-speaking 20-somethings what they think of getting therapy here. It’s not exactly a secret – if you go looking for an English speaking therapist who is covered by your Gesetzliche Krankenversicherung (GKV), the statutory health insurance, you’re going to have to join the long, winding queue. Ella*, a 31-year-old from Australia who moved here in 2016, describes the struggle of looking for psychotherapy in English: “A lot of therapists don’t have receptionists, or even answering machines. So I had to send a lot of emails. I think I sent at least 40 and got a response from three.” Having always suffered from anxiety, a culmination of typical expat problems with settling in a new foreign country and getting “fucked over” by the job she moved here for, heightened things to the point where it was either therapy or anti-depressants. Her GP recommended the former. Eventually, Ella’s persistence paid off and she got an appointment, but it wasn’t an easy process. “It was lucky timing because I was at the end of my tether. Every single level of it is hard, even trying to Google it – not being able to speak German, not being able to type in the right words, finding outdated websites with supposedly English speaking therapists that don’t seem to exist anymore.” And as many mental health professionals will tell you, getting therapy in your mother tongue, or at least a language in which you are completely fluent, is essential. After all, what you need is for someone to understand your struggle, not a game of charades.
The Psychotherapeutenkammer Berlin, the city’s mental health professionals’ association, lists a total of 4000 members in the city, of which the amount of English-speaking therapists is hard to discern. A search on therapie.de, Germany’s biggest online resource for finding psychotherapists, returns a count of roughly 1500 practitioners in Berlin, with 500 of them offering treatment in English. The language information is voluntary though, and might not be accurate. Either way, longer wait times for non-German speakers come as no surprise. Anna, 32, from Hungary has lived in Berlin for three years and is nearly fluent, but says: “Although I speak C1-level German, I feel more at ease speaking in English.” Last year, Anna tried contacting over 10 therapists, with no success. “Most of them didn’t even respond at all. Others informed me that they had no free slots, and one wrote that she doesn’t actually take English-speaking patients, even though English was mentioned on her website.” Eventually, Anna gave up, leaving Berlin shortly afterwards for work. Although she wouldn’t go as far as saying the system is failing them, she confirms that “there is definitely less availability for non-German speakers,” comparing her own experiences to that of her German friend who contacted five therapists, got two replies within a few days and had a first appointment with both therapists within a week.
Berlin prides itself on its international community, so when an expat gets ill, for the system to suddenly say: no, no, no – you’re in Germany – it’s a huge contradiction!”
“Berlin prides itself on its international community; there are so many start-ups here, so many people from all over the world, whole companies that only speak English. That isn’t just tolerated but invited, so when an expat gets ill, for the system to suddenly say: no, no, no – you’re in Germany – it’s a huge contradiction,” says Sybille Aßmann, a state-licensed psychotherapist who specialises in trauma. But why is it that the city isn’t providing the mental healthcare needed for its growing international community?
Anyone offering psychotherapy in Germany has to have gone through the German education and training system to get licensed. It is this requirement for a state license that is a stumbling block for a vast number of English-speaking therapists whose qualifications are from countries outside Germany. In order to obtain such a license, they need to prove that their qualifications are equivalent to the German diploma. When those qualifications are not approved, they must practice as Heilpraktiker, which is classified as alternative medicine and not covered by the Krankenkasse. Gill H.*, founder of a psychotherapy practice in Mitte, decided to work as a Heilpraktiker and only treat privately paying patients, because after six years of training in the UK, she wanted to get to work. “I have a B.A. in literature and a masters in a psychology program which qualifies me to be a psychotherapist, but here one must have a German Diplom,” she says. “I would have had to re-do my studies and take a German test.”
German bureaucratic processes are often huge labyrinths constructed by innumerable associations and bodies, with impenetrable walls built of extremely long, complex German words. Unfortunately healthcare is no exception. On the patients’ side, every single registered resident of Germany is required by law to pay for health insurance. Of the entire population, 90 percent has public, rather than private insurance. It is a solidarity-based system where payments are taken directly from your pay cheque each month at a rate of 14.6 percent of your income. Everyone pays the same percentage of their income and is entitled to the same treatment. A limited number of psychotherapists, currently 2400, have what is called a Kassensitz, meaning they are automatically covered by health insurance. All other licensed therapists can treat publicly ensured clients if they apply for a cost transfer from their insurance company.
Paying privately can set you back up to, if not over, €80 per session at the full rate. Not exactly pocket change. Some therapists will work on a sliding scale of payment, depending on individual situations, but it isn’t a guarantee. Evie, a 25-year-old from England, had been trying to find a GKV-covered therapist for three months before her best friend died suddenly and she couldn’t wait any longer. “I was very lucky. I was in a total crisis and she [the therapist] knew I needed help. She literally just said: ‘Tell me what you can afford’.” As not every therapist is able or ready to be this accommodating, the question of insurance coverage is crucial.
But the cost transfer process, where available, can be a long and often tedious process and insurance companies have been known to try to avoid paying. Jan Wichter, another state licensed therapist in Berlin, says: “The public healthcare system is called public, but the health insurance providers are companies in a capitalist system.” Wichter knows of colleagues who have taken cases against such companies to the Federal court over the cost transfer process. He also points to kassenwatch.de, a recently launched project to help patients and therapists when cost transfer is denied. “Some of these companies like AOK and Barmer, they just outright deny the existence of the transfer process for psychotherapy. It’s crazy,” he laughs, in total disbelief.
On top of the insurance companies’ growing reluctance to pay, the procedure is also becoming more restrictive. Since April 2017 anyone hoping for insurance to cover their treatment, has to first get an appointment for a one-off assessment session with a contract therapist to determine whether or not treatment is required. This appointment is arranged by a central office, the Terminservicestelle, within four weeks after the initial inquiry. The body running this office, the Kassenärztliche Vereinigung, stipulates in their directives concerning the service that there is no consideration of “desired” place, therapist or date. As of this month, the Terminservicestelle also provide the first probationary session with a GKV-covered therapist. “It takes away your right as a patient to choose who you are treated by,” Aßmann says. She explains that now, even if they find a therapist who can treat them, patients must fight for reimbursement with the Krankenkasse for months on end, “which is really not good when you are already having problems. Since April last year, it’s become almost unethical.”
Without question, paying for a therapist straight from your own pocket will drastically reduce your waiting time, but it’s important to remember that GKV-covered therapists aren’t “free” either. “Of course it isn’t, everyone is obliged by law to pay for health insurance, that’s how it is paid for,” says Aßmann. It’s a point Anna agrees on: “I don’t think I am supposed to get this service for free in a different language, however I do pay nearly €300 health insurance per month and cannot afford paying privately on top of that.” This is the catch-22 for a lot of Berlin’s English speakers. The anxiety and stress that can stem from the experience of emigrating from your home, arriving to a city where you don’t speak the language and are faced with a forest’s worth of paperwork before you can take your first step, is what may cause someone to seek treatment in the first place. But in order to receive treatment without the extra monetary burden they need to face exactly what is causing it.