(1) Psychotherapists’ perspectives on current collaboration.

After an overview on the psychotherapists’ general collaboration experiences, more detailed accounts on the collaboration with the most important collaboration partners and key actors in mental health care, i.e. a) GPs and b) psychiatrists will be given. Moreover, themes that were identified as c) overarching interprofessional challenges between psychotherapists and other medical specialties will be presented.

As a first overview on collaboration, psychotherapists identified GPs as most important collaboration partners, followed by outpatient psychiatrists. Among further collaborators of less overall importance were inpatient and day clinics, medical specialties such as neurology, counselling services and self-help groups. The overall intensity of collaboration varied from rarely to regularly, with most psychotherapists wishing for more collaboration. Yet, not all interviewees saw a closer collaboration as necessary: “I’d say, each of us is doing his job.” (M, PD). Higher intensity of collaboration was often linked to small local networks built over time with GPs and/or psychiatrists with whom the interviewees “felt to be on the same wavelength” (M, PD).

Collaboration was only initiated or intensified when needed, due to omnipresent time pressure and unavailability by phone on both the psychotherapists’ and the collaborators’ side. While the interviewees mainly considered themselves as initiators of collaborative exchange, some critically reflected on their own lack of initiative to foster collaboration and to improve availability for collaborators. The structural barriers of time pressure and unavailability played a major role in the accounts of the psychotherapists and were further reinforced by the lack of remuneration for collaborative activities between these professional groups in German health care. Reasons for collaboration were somatic differential diagnosis and somatic health care, formal constraints (such as a short medical report necessary for the reimbursement of psychotherapy), complex or acute cases or the transition between general and mental health care. The collaboration with inpatient and day clinics was considered to be of comparably lower importance to psychotherapists’ daily practice. However, this collaboration was equally impeded by the barriers of time pressure and mutual availability and facilitated by personal contacts.

Regarding the collaboration with GPs, psychotherapists reported heterogeneous experiences. Apart from relevant structural barriers (e.g. time pressure), the GPs’ varying interest and competency in mental health care were considered as main influence on collaboration. GPs were generally assumed to be rather open-minded towards mental health problems compared to other medical specialties.

The main benefit of collaborating with GPs was seen in exchanging valuable information on the patient from both perspectives: While GPs often had long-term relationships with their patients and a practice team adding further information, psychotherapists pointed to the depth of their psychotherapeutic work. With regard to referrals, psychotherapists valued some GPs’ good intuition for a patient’s openness for psychotherapy or their preparatory work: “Sometimes, GPs had already invested months or even years to persuade the patients so that they are willing to say ‘Okay, I’ll give this shrink a chance” (M, PD).

In contrast, other GPs were deemed to not assume mental health as part of their responsibility, only dealing with their patients’ mental health concerns because of the shortage of psychiatrists. In some cases, the contact with GPs was described as “strenuous” (P, CBT), leaving the notion among the interviewees of not being valued or treated as equal and important care providers: “I don’t think that they really see a sense in what we’re doing.” (P, CBT).

One major and recurring criticism issued by psychotherapists was the lack of mental health competencies in GPs: “[…] But there are many, many other [GPs] (…) who go through their whole array of somatic diagnostics and then end like ‘could be something mental’.” (M, PD)

This resulted in varying degrees of frustration or even anger among the interviewees: “They’re often not trained well and yet they think they are. This is when it gets difficult.” (P, CBT). Specifically, interviewees criticized GPs for sometimes being too quick in labelling patients as mentally ill, for prescribing psychopharmacotherapy too often, for putting patients on sick leave too early or too long or for referring patients without appropriate indication for psychotherapy.

The collaboration with psychiatrists was strongly influenced by the perceived shortage of outpatient psychiatrists, resulting in an overload of available practices:

I’d like to have someone [a psychiatrist] saying ‘If you call me and want to refer your patient to me, you’ll get an appointment within a week’. I really do find it hard, if I say ‘I do have a suicidal patient sitting here, could you please take a look at him today?’ and the answer is ‘Sorry, I’m full’. (M, PD)

The collaboration intensity with psychiatrists varied, with only a few interviewees being satisfied and most wishing for more exchange. As with GPs, collaboration was facilitated within small networks, while contact with unknown psychiatrists or neurologists was seen as “practically non-existent” (M, PD).

Disregarding these difficulties, interviewees described the exchange as mostly cooperative, especially when based on previous personal encounters. The psychiatrists’ professional evaluation on specific patients was partly valued as feedback for the psychotherapists’ own impression. Asked about what psychiatrists might think about psychotherapists, one interviewee suspected that “They [the psychiatrists] laugh about us. Because, I think, we don’t present ourselves as one coherent group and we don’t act as competent in every aspect as we could.” (P, CBT).

As part of the psychotherapists’ perspectives on collaboration, overarching interprofessional challenges between psychotherapists and other medical specialties became apparent.

A major hindrance to collaboration was seen in general “territorial claims” (P, PD) between the different specialties, partly due to questions of power but also due to different professional socializations. For instance, psychotherapists criticized that sometimes other medical specialties treated patients‘ symptoms from an exclusively biomedical perspective:

Sometimes patients tell me that their orthopedist treats their pain with injections that only help for a few days or so, without treating the underlying problem. Or a patient gets x-rayed or has an MRI (…) without ever looking beyond. (P, CBT)

While one interviewee admitted that every specialty had its own “codes” and “models” (M, PD), a too rigid biomedical focus was considered as hindrance to a constructive interprofessional dialogue and as barrier to a patient’s willingness to engage in psychotherapy: “I experience some physicians as narrow-minded, those who fix patients on a specific model in a problematic way. Yet, in everyday practice there is no constructive dialogue on this.” (M, PD). Moreover, some psychotherapists criticized that physicians were often ill-informed about psychotherapy and the different psychotherapeutic approaches: “They have little insight into what psychotherapeutic work actually is and how diverse psychotherapeutic work can be.” (P, CBT).

While interviewees deplored the perceived lack of esteem for psychotherapy by some medical specialties, this impression was further reinforced by the general feeling of devaluation that some psychotherapists experienced within the health care system, e.g. by an insufficient remuneration or additional regulations:

You don’t gain this impression [that psychotherapy is valued] in our health care system (…) although everyone cries for it and everyone says ‘Mental disorders are on the rise’. You don’t get the impression that hindrances are removed. And it really would help if things got easier instead of new regulations all the time. (M, PD).

(2) Psychotherapists‘ perspectives on stepped care.

In the following, psychotherapists’ perceived benefits as well as barriers and disadvantages on stepped care will be presented with regard to (a) the concept in general and (b) with regard to collaboration. As described, the evaluation mainly relied on the standardized input on stepped care, not on previous practical experiences.

From the psychotherapists’ perspective, the general concept of stepped care was partly appreciated for its benefits. Stepped care was considered a chance for timely recognition and treatment of mental disorders, for “using the possibilities to turn around early when symptoms arise” (P, CBT). The diversification of care in different steps was generally welcomed as useful for the allocation of resources and for low-threshold services for patients still reluctant to engage in psychotherapy. Seen from the patients’ perspective, psychotherapists partly appreciated that GPs should function as access to stepped care: “If a GP is involved, this would probably make it easier for a patient to understand himself within the health care system.” (P, CBT). Structured care pathways could allow for a better overview of the available treatments for both care providers and patients. To foster this, one psychotherapist suggested to establish “a network coordinator” (P, CBT).

With regard to monitoring, as second core principle of stepped care, the interviewees saw an opportunity to regularly review the therapeutic progress and to allocate resources according to needs, rather than only exhausting the predefined contingent of psychotherapy sessions as granted by the insurance.

In contrast to the benefits, psychotherapists also identified barriers and disadvantages in the concept of stepped care. While the stepping of care was generally considered as useful, several psychotherapists questioned the novelty of the approach: “Don’t we do this already?” (P, CBT). Regarding the conception of treatment steps and care decisions for individual patients, the interviewees worried that their proficiency would not be adequately considered, e.g. that they would not be allowed to self-dependently adapt the number and frequency of sessions to a patient’s need.

Concerns were raised that within stepped care the treatment might no longer follow the “organic” (M, PD) psychotherapeutic process that allows for symptom fluctuation as part of progress without being immediately tied to stepping-up/down-criteria. This concern corresponded to the objections against monitoring since psychotherapists (especially with psychodynamic background) questioned the measurability of therapeutic progress with questionnaires: “Depending on the state a patient is in and whether he currently is in a conflict with his therapist, the results might be really weird.” (P, PD).

In addition, regular measurements would increase the administrative burden which generally was a predominant worry raised against stepped care. Major opposition was pronounced against the idea that stepped care could primarily serve economic principles like cost-effectiveness and cost-savings at the expense of treatment intensity and length a patient might need: “The patient might get the feeling of being under pressure because he is constantly asked how he feels and when he’ll finally function again.” (M, PD). For the same reason psychotherapists feared the potential replacement of psychotherapy by unguided e-health interventions within stepped care, both with regard to patients with mild disorders who might be “put off with some kind of computer program” (M, PD) and with regard to the mental hygiene of psychotherapists “because it’s good if, on the one hand, I treat severely ill borderline patients (…) and, on the other hand, a first depressive episode where treatment is going smoothly.” (P, CBT).

Additionally, the interviewees argued for retaining patients’ free choice of care providers and for not predetermining care pathways too tightly as this could “nip the patients’ own responsibility in the bud” (M, PD) despite this being considered as important for the therapeutic process.

As to the benefits of stepped care for collaboration, the intensified collaboration within stepped care was considered the most important benefitespecially between GPs and psychotherapists, provided more time and remuneration for collaboration was available. More collaboration was deemed particularly useful regarding complex cases and cases with relevant somatic and mental symptoms, such as somatoform disorders or comorbidity of chronic health conditions and mental disorders.

Several barriers and disadvantages of stepped care for collaboration were described by the psychotherapist. Although the interviewees unanimously welcomed the idea of fostered collaboration, its implementability within the present health care system was challenged. Besides the lack of time, resources and remuneration, one recurring criticism addressed the deficient mental health competencies of GPs, who would play a major role within a stepped care model anchored in primary care. Thus, further GP training and earlier requests of psychotherapeutic competencies in the diagnostics and treatment process were suggested as precondition for successful stepped care. These reservations against decision power transferred to less competent care providers were fostered by the aforementioned impression of some interviewees that psychotherapists were not adequately valued.

Thus, while stepped care was overall deemed a positive concept, especially with regard to collaboration, skepticism concerning its implementation and the appropriate consideration of psychotherapists within it was distinct.