Where are the treatment centers??

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

Depression, anxiety or trauma – the list of 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 of the matter 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 at the Schaffhausen hospitals talk about how the lack of therapy places burdens them.

"I was turned away 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 suffered at the time triggered a moderate depression in her. "I made an emergency presentation to the crisis intervention center at Breitenau," she reports. "Since I wanted to do without medication, inpatient treatment was out of the question for me." She had to wait for 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 later four-and-a-half-month stay in the clinic, she started her first psychotherapy. "After leaving the clinic, it took a lot for me to be allowed to stay with my therapist."This resulted in a very irregular therapy, which was accompanied by a very high fluctuation rate. "Nobody likes to change psychotherapists," she laments. She launched the final search attempt in late 2022. She had made at least eight to ten phone calls. "At best I got on the waiting list, most of the time I was put off directly," reports J. "I had long held out hope that someone would eventually get back to me. But I have not found anyone else until today."She decided to switch 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. two options: Either there would have to be more points of contact or additional offerings in the form of support groups. "It is important to realize that you are not alone."

High effort

H.* is 26 years old and has been in psychological care for about a year now. She was also diagnosed with depression. "First I saw a psychiatrist and then, after my stay at the clinic in the summer, 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 in the crisis intervention center. "There I was turned away and given a list of names of psychiatrists in Schaffhausen," says H. "These I began to phone through.She had made at least ten calls, and the answer everywhere was: "Nothing more is possible in the next month or two. "If you don't have any power anyway and then you get turned down, ultimately you feel even less like calling someone again." She would like to see on a website if a therapist still has free capacity. "Rejections are very difficult for me to cope with."

H. is now placed in psychological counseling. "My luck is that the therapist is also a qualified psychologist. I feel I'm in very good hands with her." What she also regrets: that her health insurance only covers 1000 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 in this way." 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. This is a big hurdle that can quickly inhibit you."

Ten refusals out of ten requests – in the canton of Schaffhausen it is very difficult to find a psychotherapy place. Not only those seeking help suffer, but therapists as well. Picture: Lara Gansser, Schaffhausen24

"It is not manageable"

The situation for those affected is deplorable. But the situation is no better for therapists. "For us psychotherapists the situation is very difficult. 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 worked as a psychologist for 25 years and has had her own practice in the middle of Schaffhausen's old town for the past 15 years. "The average is one to two requests per day, yesterday there were even four," says Doris Kunstner. "It's not manageable and it's getting more and more."The problem has increased again since the summer of 2022 with the decision that psychotherapies with psychologists can also be billed via 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 to feel the suffering of those affected and to have to cancel is very difficult for us." Doris Kunstner no longer keeps a waiting list. Regarding the option of a traffic light system, she only says: "With us, all traffic 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

Allocations almost impossible

Andreas Reich is a specialist in psychiatry and psychotherapy. He presides over the Schaffhausen Association of Specialists in Psychiatry and Psychotherapy (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 continuous load is also a huge challenge for our established medical profession," says the specialist doctor. "Referrals to a psychiatrist are almost impossible."The problem was already an issue 20 years ago, but it has become much more explosive in recent years. "We simply have an undersupply," says Andreas Reich. "And the demand continues to grow."

In addition to the increasing pressure in society, the removal of taboos surrounding mental illness is a major factor in more people seeking help. "A generation is 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 specialists? Far too few people are trained – and of those who are trained, only a few find their way into psychiatry. "We are the worst paid group of physicians," says Andreas Reich. On the psychologist 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 hospitals Schaffhausen. 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, financing is also a major challenge. "It would be absolutely necessary for us to be able to offer more outpatient therapy places."Bernd Kramer hopes that the canton of Schaffhausen will soon respond to this nationally burning issue with financial support.

Moreover, the crisis intervention center mentioned by those affected is not a final therapy center. "The goal here is to be able to offer help once 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 need exceeds the supply strongly."

Discussions around the issue are in full swing at Schaffhausen hospitals. "One approach would be to switch to alternative models," says Bernd Kramer. Creativity is needed here. "Whether it's coaching, specially trained nurses or digital tools – we have to find offers where the 1:1 contact takes more of a back seat."

Creating contact points

As a possible solution, Andreas Reich suggests the creation of a superordinate point of contact. "Professionals from different occupational groups can be brought together here," says Andreas Reich. "Requests" can be received and appropriately cushioned and assigned."

Furthermore, prevention and health promotion are gaining in importance. "Anything that is addressed preventively is very helpful and ultimately takes the pressure off 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 nearing retirement age. In conclusion, Doris Kunstner says: "It would also be important that the stress and pressure we live with, as well as the demands we make on ourselves, finally become less," says Doris Kunstner. "The constant idea of efficiency is not good for us, we are not machines."