Where are the therapy places?

More and more people want to make use of psychotherapy. But the demand massively exceeds the supply: The situation is a great burden for those seeking help as well as for the therapists.

Depression, anxiety or trauma – the list of reasons why people seek psychotherapy is long. And the list of how many people want therapy and can't find a place is even longer. The urgency in the canton of Schaffhausen quickly became apparent during the research of the "Bock". Two patients, a psychologist, a psychiatrist and the head of the clinic for psychiatry and psychotherapy as well as the head of psychiatric services of the Schaffhausen hospitals talk about how the lack of therapy places burdens them.

"I was rejected again and again"

J.* is 44 years old. The first time she came into contact with the subject of psychotherapy was four years ago. A burnout she suffered at the time triggered a moderate depression in her. "I went to the crisis intervention center at Breitenau as an emergency," she says. "Since I wanted to do without medication, inpatient treatment was out of the question for me." She had to wait three months before she was admitted to the day clinic of the Schaffhausen hospitals. "My good fortune was that my former employer offered an Employee Assistance Program, where I received weekly phone support," says J. During her subsequent four-and-a-half-month stay in the hospital, she started her first psychotherapy session. "After leaving the clinic, it took a lot for me to be allowed to stay with my therapist." This resulted in very irregular therapy, which was compounded by a very high turnover rate. "Nobody likes to change psychotherapists," she regrets. She made her last search attempt at the end of 2022. She had made at least eight to ten telephone calls. "At best I got on the waiting list, mostly I was put off directly," reports J. "I had long had the hope that someone would eventually get back to me. But I have not found anyone else until today."She decided to turn to mental coaching, where she feels she is in good hands. "Unfortunately, coaching is not recognized by the health insurance company."

When asked what it would take to counteract the problem, J sees. two possibilities: Either there would have to be more points of contact or additional offers in the form of self-help groups. "It's important to realize that you're not alone."

High effort

H.* is 26 years old and has been in psychological care for about a year. She was also diagnosed with depression. "First I went to a psychiatrist and after the hospital stay in the summer to a psychologist." Soon after, her therapist dropped out. "Then suddenly I had no one because there was simply no substitute," reports H. She was also in the Breitenau crisis intervention center. "I was turned away there and received a list with the names of psychiatrists in Schaffhausen," says H. "These I began to phone through.She made at least ten phone calls, and the answer everywhere was: "Nothing more is possible in the next one to two months. "If you don't have any strength anyway and then you get rejected, you ultimately have even less desire to call anyone again."She would like to see a website showing whether a therapist still has free capacity. "Cancellations are very difficult for me to cope with."

H. Has now been placed in psychological counseling. "My luck is that the therapist is also a certified psychologist. I feel very well taken care of by her."What she also regrets is that her health insurance company only pays 1000 Swiss francs per year for psychological counseling as opposed to psychotherapy. "I don't know if I can afford to treat my illness in the long term like that."In addition, there is the enormous bureaucratic effort with the health insurance company. "For example, you have to take care of every referral through your family doctor yourself. It's a big hurdle that can quickly inhibit you."

Ten rejections out of ten inquiries – in the canton of Schaffhausen it is very difficult to find a psychotherapy place. Not only those seeking help suffer from this, but also the therapists. Image: Lara Gansser, Schaffhausen24

"It is not manageable"

The situation for those affected is deplorable. But the situation is no better for therapists. "The situation is very difficult for us psychotherapists. The immense demand for therapy places is a great challenge," says Doris Kunstner. The self-employed psychotherapist is president of the Schaffhausen Psychotherapists Association (SCHaP). She has been working as a psychologist for 25 years, and has had her own practice in the middle of Schaffhausen's old town for the last 15 years. "The average is one to two inquiries per day, yesterday there were even four," Doris Kunstner tells us. "It is not manageable and is becoming more and more."The problem has increased again since the summer of 2022 with the decision that psychotherapies with psychologists may also be billed through the basic insurance – a very important step with regard to the basic care of the population. "It is basically gratifying that more and more people are making use of psychotherapy," says Doris Kunstner and adds. "But feeling the suffering of those affected and having to cancel is very difficult for us." Doris Kunstner no longer keeps a waiting list. As for the option of a traffic light system, she simply says: "With us, all the lights would always be red. And when a place is free, the phone rings again within the next few hours."

""Every week there are 10 to 15 requests for therapy places"" Andreas Reich, specialist in the field of psychiatry and psychotherapy

Referrals almost impossible

Andreas Reich is a specialist in psychiatry and psychotherapy. He presides over the Schaffhausen Association of Psychiatrists and Psychotherapists (SAPP), the counterpart to SCHaP. "Psychotherapy is our common field," says Andreas Reich. His statements coincide to a large extent with those of Doris Kunstner. "The constant workload is also a huge challenge for our practicing physicians," says the medical specialist. "Referrals to a psychiatrist are almost impossible." The problem was also an issue 20 years ago, he says, but has become massively more explosive in recent years. "We simply have an undersupply," said Andreas Reich. "And the demand continues to increase."

In addition to the increasing pressure in society, the removal of taboos surrounding mental illness is a major factor in more sufferers seeking help. "There is a generation growing up that is much more open about the subject, which is very gratifying," says Andreas Reich. Every week, ten to 15 calls, e-mails and referrals reach the psychotherapist.

Where he sees the main reason for the shortage of skilled workers? Far too few people are being trained – and of those who are trained, few find their way into psychiatry. "We are the worst paid group of physicians," says Andreas Reich. On the psychologists' side, the situation is similar: "What we have now is the result of the previous framework conditions," says Doris Kunstner. "Until last summer, it was very unattractive to open your own practice."

"We need more therapy places"

The issue has the same explosive nature at the Schaffhausen hospitals. Bernd Kramer, who has been head of the Department of Psychiatry and Psychotherapy and head of psychiatric services since 2017, says: "The shortage of therapy places has existed for years." In addition to the massive shortage of specialists, he says, funding is also a major challenge. "It would be imperative that we can offer more outpatient therapy places." Bernd Kramer hopes that the canton of Schaffhausen will soon respond to the nationally burning issue with financial support.

Moreover, the crisis intervention center mentioned by those affected is not a final therapy location. "The aim here is to be able to offer one-off help within 24 to a maximum of 48 hours and to provide support in the search for a follow-up solution," says Bernd Kramer. "But here we are again at the same point – the demand greatly exceeds the supply."

Discussions on the subject are in full swing at the Schaffhausen hospitals. "One approach to a solution would be to switch to alternative models," says Bernd Kramer. Creativity is needed here. "Whether coaching, specially trained nurses or digital tools – we need to find offers where the 1:1 contact is more in the background."

Create points of contact

As a possible solution, Andreas Reich suggests the creation of an overarching point of contact. "Here, professionals from different professions can be brought together," says Andreas Reich. "Requests can be received and cushioned and assigned accordingly."

Further, prevention and health promotion are gaining importance. "Everything that is approached preventively is very helpful and ultimately relieves us," says Doris Kunstner. Because there is currently no end in sight to the shortage of specialists: Many of the working psychologists and psychiatrists are approaching retirement age. Doris Kunstner concludes: "It would also be important that the stress and pressure we live with, as well as the demands we make on ourselves, should finally be reduced," says Doris Kunstner. "The constant idea of efficiency is not good for us, we are not machines."