Covered and waitlisted

By Sherley De Deurwaerder, Mika LorangMisch Pautsch

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After the Covid-19 pandemic, the national psychotherapeutic system is facing a sudden rise in demand. Waiting lists are long, the more so since the new reimbursement legislation, and getting psychotherapeutic care is harder than ever. How can we facilitate access to clinical psychological care?

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"I was doing everything I could, sending emails, calling, everything, but that was a complete failure. All I got was 'We can’t take you in', 'According to waiting lists you could maybe get treatment by June', and so on. And of course, the system is overloaded, even the more so now with the reimbursement agreement, but to me it feels like they don’t even try taking in new people anymore."

Diogo is 21 years old and highly aware of the critical state he finds himself in. After a lifetime of experience with mental health care professionals and holding a list of an estimate number of 30 contacts, he did not see it coming that in February 2023, when he decided to seek out professional help after weeks of being repeatedly confronted with past traumas, he would be left stranded in front of closed doors. Fiercely, his voice dripping with disappointment, he tells us: "Now it’s mid-April, and I’m still nowhere near to getting the help I need. I don’t have any access to the service anymore. Tough Luck, Diogo, turns out you’re just a peak example of a young person that is a victim of a system, a young person that got caught up in some ironic ping-pong game in which you are the ball, and the professionals are the players. They force me into relapse, and they put my life at risk, they play around with it. Do I really need to get hospitalised again to get help, does the worst-case scenario have to take place for me to get the necessary treatment?"

Restricted access

The young member of the LGTBQ+ community is not new to dealing with the national mental healthcare system. He was four years old when he was first dragged to a psychotherapist by his day-care centre, and when he was nine the youth welfare office insisted on the necessity of an official assessment of the effect the abusive conditions he was raised in was having on his healthy development. Throughout his teenage years he grew prone to committing suicide and regularly ended up at the school counsellor’s. Then, finally, in the aftermath of the first lockdown, he decided to autonomously seek out psychotherapeutic treatment.

Development of mental illness

  • On their official website, the WHO (World Health Organization) illustrates the major causes of the development of mental illness. The manifestation of mental illness is commonly triggered by a complex interplay between individual, social and structural components. Oftentimes mental illness is rooted in early childhood due to its status as a developmentally sensitive period. Frequent exposure to emotional and physical abuse, both witnessed and exerted upon in either domestic or public settings, figures as one of the main predictors of the subsequent manifestation of mental illness. Equally, being confronted with inauspicious social, economic, geopolitical and environmental circumstances throughout life can be detrimental to mental health. Genetics may also play a role in the development of mental health conditions, as well as substance use.

    However, the predictive strength of the above-mentioned risk factors is limited. Mental illness can develop independently from these factors or may not develop despite frequent exposure to them.

"This is the first time that I am being confronted with waitlists, " he explains. "In my final year of high school, that was in 2021, the SePAS (Service Psycho-Social et d’Accompagnement Scolaires, ed.) drove me to the Hôpital Robert Schuman after I had a breakdown. They wanted to keep me there for three days – I didn’t want that, because I couldn’t let my family know what state I was in, that would have worsened it all. The psychologist from the SePAS managed to make a deal. I would be exempted from class for the semester so I could get treated at SDIP (Service de Détection et d’Intervention Précoce, ed.). After a few months they referred me to a psychotherapist specialising in PTSD (post-traumatic stress disorder, ed.)." His treatment got interrupted due to his moving out of home and being overburdened with subsequent administrations, and in April 2022, he admitted himself to the hospital after going through a severe psychological crisis. Ever since then, he has not been able to access the psychotherapeutic services he so urgently needs.

Diogo’s experience with waiting lists is not a singular phenomenon. It seems evident that Luxembourg currently suffers from a mismatch between offer and demand within the psychotherapeutic care system. With an average waiting time of six months on top of potential language barriers, getting adequate and immediate psychological care compares to finding the needle in the haystack.

"It is scary, having to somehow cope with mental problems and battle states that restrict your consciousness, all on your own."

Diogo, waiting for treatment

At the professional end, Catherine Richard, practising clinical psychologist and president of Fapsylux, has stopped putting people on the waiting list. "Each day I get calls by 10 new people, and I can’t each day add 10 additional people to a waiting list, " she explains. Genuine regret feeds into her voice. She links the steep increase in demand at least partially to the reimbursement agreement between Fapsylux and the CNS. According to her, a psychotherapist can see four to five clients per day without the quality of the offered services being impacted negatively. Anything above that number proves as difficult to manage. Treating mental illness and building a productive relationship between patient and psychotherapist requires a lot of focus and patience. "Usually, as a psychotherapist, you have to think ahead to get your patient to a certain realisation. You can’t just lose focus mid-session."

Catherine Richard

But why is the psychotherapeutic system this overburdened, as much in Luxembourg as on an international level, and why do we lack in a sufficient offer of psychotherapeutic access points? Catherine Richard guides us through the process of becoming a licenced psychotherapist. Five years of university studies, plus another additional four to five years of training. "Internships are not paid. After finishing my master’s degree, I went to work for one and a half years, and that was not remunerated. Working as a psychologist, this is something that you will have to want to do, you really have to put your heart into the profession. It requires a lot of time, patience, and it rarely turns out to be well-paid in the end. We sacrifice a lot for our work." Evidently, becoming a clinical psychologist requires a lot of stamina and dedication.

A new international model

  • On 1 September 2020, Germany has passed a law reform for psychotherapist training due to the necessity to adapt the law to the qualifications of psychotherapists and to improve the profession’s training conditions – thus, to attract more future psychotherapists. Unlike in the other European countries, specialised psychotherapeutic training in Germany begins during university studies and is concluded with a licensing exam after the completion of a master’s degree in psychology or psychotherapy, i.e., training is completed through direct study. Psychotherapeutic trainees in Germany must be paid as employees, and training institutions must cover at least 40 per cent of the health insurance fees. The law reform is fruitful in that training does not follow a master’s degree but is included in it – and is financially rewarded. The psychotherapeutic job title can be acquired quicker, and thus the professional world can be entered quicker, but in a carefully regulated manner.

Catherine Richard and Prof Dr Claus Vögele, Director of the Master programme in Psychotherapy at the University in Luxembourg and licenced psychotherapist, agree on the following: The number of psychotherapeutic services offered does not correlate with the demand for help, the demand is only going to further increase, and action is necessary. At first glance, the solution seems easy: Create new positions, attract across-the-border workers, and invest in psychotherapeutic care provision.

Prof Dr Vögele shakes his head. "If you talk to people from the CNS, then they have a certain budget, and they need to allocate it. They cannot just increase the budget, " he cautions. The course a mental disorder may take is not uniform, and consequently, exactly planning expenses is difficult. Some patients will require more sessions than others, thus some are going to cost the CNS more than others. Opening additional psychological institutions will have to be proven as lucrative and requires careful planning.

"There are studies in Germany that indicate that for every euro invested into the provision of psychotherapeutic services, four euros will be gained on the long run."

Catherine Richard, psychotherapist and president of Fapsylux

Despite of this concern, the professor proposes a free market thinking approach. "I have had discussions with people from various parts of society, who said: 'Oh, you’re going to churn out a huge number of psychotherapists that are going to be without work, because there are not sufficient positions.' This is hardly free market thinking, because if you adopt free market thinking for a moment and you actually take the demand, then a larger number of new positions should be created, which reflects the demand." Both professionals argue that improving the accessibility of psychotherapeutic services would be economically beneficial to both society and professional settings. It would significantly decrease absenteeism from work and early retirements and enhance productivity.

The benefits of the reimbursement agreement

The new legislations concerning the reimbursement of psychotherapeutic services strikes both prospective patients and psychotherapeutic practitioners as an undeniable relief. Catherine Richard explains the German influence on this agreement.

Reimbursement of psychotherapeutic service sessions

  • As explained on the official website of the Caisse Nationale de la Santé, costs of psychotherapeutic services can be reimbursed since 1 February 2023. Adults are covered by health insurance 70 per cent, and insured minors are reimbursed 100 per cent of expenses. Reimbursement of supportive and extended supportive psychotherapy is only possible if a medical prescription certifies that no somatic condition is at the root cause of psychological disorder. Reimbursement can only be claimed if the treatment is started within 90 days of the issued prescription. The introductory psychotherapy sessions, limited to three sessions, does not require a medical subscription before the beginning of the session, but it must be issued within 90 days of the first session. Coverage acts are limited in time: Patients can claim reimbursement of three introductory psychotherapeutic sessions and 24 supportive psychotherapeutic sessions every 5 years, calculated from the issue date of the original medical prescription. Up to 120 extended supportive psychotherapeutic sessions every 10 years may be covered by health insurance, under the condition of the presence of a renewed medical prescription for each 24 sessions.

"The German healthcare system has reimbursed psychotherapies since the beginning of the 1990s. So, the profession has been recognized for much longer, and more people are interested in working as psychotherapists there. We wanted to adopt that idea to our national system." She is hopeful that it will positively affect working conditions within the national field. More professionals should be attracted to work in the field in the future, as it now is more lucrative. Prof Dr Vögele also seems relieved. "We must keep at the core of our concern the welfare of our patients. And we need to be ethical in our approach, and one of the ethical requirements is to offer services to anyone." The reimbursement agreement eliminates the prior border between rich and poor, dethroning psychotherapy from its status as a service exclusively available to those who can afford it.

Physical versus mental disease – a longstanding warfare?

Nevertheless, what presents itself as a step forward finds itself anchored within the general stigmatisation of the experience and treatment of mental illness. The presence of a medical prescription figures as the main condition for the coverage of costs: As can be read on the official CNS website, to be eligible for reimbursement from the CNS or the competent public sector fund, ‘all services provided by a psychotherapist must be prescribed by a doctor, certifying that there is no medical contraindication to psychotherapy’. Prof Dr Claus Vögele laughs in disbelief. "I can’t see why a referral by a general practitioner, or any kind of medical doctor, would be necessary if someone experiences mental problems." The CNS here treats psychotherapy as an adjunct paramedical treatment, driving a wedge between the mentally ill and psychotherapists. "This is only going to create additional hurdles for people." Medical doctors are guarding the gates of psychotherapy – and this without necessarily possessing any of the necessary qualifications for adequate clinical assessment.

"Mental disorders need to be assessed according to the state of the art. (…) Otherwise, decisions go wrong at the very first junction."

Prof Dr Claus Vögele, Director of the Master programme in Psychotherapy at the University in Luxembourg and licenced psychotherapist

This tension between physical and mental disorder has a very longstanding history that both Catherine Richard and Prof Dr Claus Vögele are concerned about. "'You’re at fault, stop whining' – recently, I was on vacation and we were talking about an ill person, a person suffering from depression. And somebody said 'Oh okay, I thought it was cancer.' People need to realise how lethal a depression can be. 15 per cent do not survive a depression because they end up killing themselves." Catherine Richard’s look softens. "A depression truly is something terrible, and it could be treated so easily through psychotherapy." Further reinforcing the division between physical and mental disorder could prove to be problematic to the overall improvement of the system.

"Not just nice talking" – why psychological care matters

Each of the interviewees emphasises the importance of appropriate treatment of mental illness, and the necessity of the provision and accessibility thereof. "You cannot manage mental illness all on your own." Diogo’s lifelong battle with mental illness has not immunised him to its detrimental effect on his everyday life and thinking.

In June 2020, his first self-appointed encounter with a mental health care professional has, against his own expectations, resulted in the immediate tentative diagnosis of MDD (Major Depressive Disorder) and the prescription of antidepressants. Diogo was disappointed. "I rejected medication. Pills cannot just fix my head. What I want is to be able to live a better life, not to escape the pain through drug consumption. That would just add to the problem."

Catherine Richard and Prof Dr Vögele elaborate on the position of a psychotherapist within a patient’s life. Empathetically, Richard describes her profession as a means to understanding and living with a mental condition, as a way into social reintegration. An excessive reliance on medication hinders the actual processing of individual mental illness experience. Psychotherapy initiates a journey to the core of deeper underlying issues. Getting to that core takes time and implies the future healthy management of emotion. "Medication numbs out the pain you feel from having a stone in the shoe – psychotherapy removes the stone."

© Philippe Reuter

Prof. Dr. Claus Vögele

Prof Dr Vögele accentuates that the brain essentially cures itself through the learning and unlearning of psychological processes. A psychotherapist points people towards marshalling their own healthy resources. "In my role as a psychotherapist I’m only the crutch on which the person starts to learn to walk again, and I’m being thrown away after it has happened." The wall built by the popular perception of the psychotherapeutic profession as a casual chit-chat between a physically healthy patient and a professional practitioner needs to be torn down.

"Mental disorder needs to be treated and we have the means for it. It is in the responsibility of any society (…) with a decent health care system to take care of that."

Prof Dr Vögele

Do we find ourselves in a hopeless situation – will we never be able to counterbalance the demand with the offer? Will psychotherapy always be looked down upon as inferior to other paramedical professions? The common consensus: No, but a lot of work has to be done, as well in society at large as concerning legislations. The coverage by health insurance is a crucial first step into the right direction, despite the referral issue. This obstacle could be overcome through a collaboration between psychotherapists, psychiatrists, and medical doctors, Prof Dr Vögele argues – a mission which the national Ministry of Health is in favour of. A national mental health plan is currently in the making. "I think it is high time that we do that. And, I think, one of the core missions of that national mental healthcare plan is to bring mental health services together that have coexisted, without necessarily knowing of each other, not to mention, collaborating with each other."

Ligue Luxembourgeoise d’Hygiène Mentale

  • D’Ligue Luxembourgeoise d’Hygiène Mentale seeks to destigmatise mental illness by sensitising the population to mental illness, their treatment, frequency of occurrence, and intervention. Its educational program is directed towards particularly suffering individuals, their immediate surroundings, and professionals from social and medical-psychosocial sectors, but are open to anyone. Training programs take place over two consecutive days, either in French or in Luxembourgish. In addition to those programs, conferences and discussion workshops inform among others about preventive identification of suicidal crisis and point towards the understanding of, and therefore appropriate reaction to and prevention of depression, anxiety, post-traumatic stress disorder, and addiction.

Prevention – another term frequently used by our interviewees. More mental health professionals are urgently needed, yes, but curbing the manifestation of serious mental illness is a social responsibility. Prof Dr Vögele repeatedly insists on the crucial role of education and appropriate training. What are mental disorders? How do we recognise early symptoms? Whom do we address when we notice significant changes in behaviour and emotionality in those closest to us, in those we raise and teach? Spoiler: It should not be the general practitioner first things first.

This article is part of the practical workshop "Working in the Media" at the University of Luxembourg. The students Sherley De Deurwaerder and Mika Lorang are the authors of the publication and gained a global insight into the daily work of journalists. Melody Hansen, editor-in-chief, supervised them as they worked on their first journalistic article.