Letter from Germany

September 1995

Two kinds of political issues have preoccupied German psychoanalysts lately: (1) the relationship between psychoanalysis, the German insurance system, and its implications on training; and (2) the importance of the Nazi regime and the national socialist militancy of some of the “founding fathers” of the postwar German psychoanalytic movement.

1German health insurance is a comprehensive system that covers practically the whole population of the country. It was conceived by Bismarck in the last century when he took measures to counter social unrest and demands for better living and working conditions. In the beginning it only covered the working classes on matters of physical illness, but with time it evolved. Since the end of World War II it has become an all-embracing health system covering all health risks except psychological ones, which only became subject to insurance payments after 1967 as a result of prolonged talks with all psychotherapeutic societies and institutions. The insurance system agreed to pay for a psychoanalytic treatment of four weekly hours of 50 minutes up to a total of 300 sessions (with some elasticity above this total number if justified by a report). Candidates were paid for their training cases if supervised by a training analyst. Nonmedical candidates and practitioners were part of the system if they were supervised or had their patient delegated by a psychoanalyst with a medical degree.

As with all health systems that started by being generous and comprehensive, time has produced a financial erosion and has made the insurance institutions look for ways to save money. These savings have targeted, amongst others, psychotherapy and psychoanalysis, and have led to attempts to restrict payments for these procedures by trying to restrict the frequency of analytic sessions to three weekly hours and certainly not finance any sessions beyond 300. If the patient and the analyst agree about the necessity and desirability of a fourth or