Violence, depression, suicidality: the pandemic has exacerbated the problems of many children and young people. They sometimes wait a very long time for psychiatric help. A new regulation for psychologists should improve the situation – but at what price?
“Nobody expected the current situation”: The demand for psychotherapy for children and adolescents has not decreased even after the pandemic.
The Corona measures are – for the time being – passé. This is particularly important for one group: children and young people. They probably suffered the most from the restrictions. “They absolutely need the outside world to cope with their developmental tasks,” says Yvik Adler, co-president of the Federation of Swiss Psychologists (FSP). «How do I arrive in the outside world, what are my talents? You can’t test that alone in a quiet little room.”
Children and young people also absorb the burdens of their environment. And Corona put many families in turmoil: fear for their own health or that of their grandparents, stress in the home office, worries about their own job. Those who had previous exposure had a high risk of developing a mental disorder.
Since then, specialists in psychology and psychiatry have noticed a sharp increase in illnesses: more restlessness and aggressiveness in children, more depression and suicidal tendencies in adolescents. The University Psychiatric Clinics in Basel recorded between 30 and 40 percent more registrations from summer 2020. In Bern last year, 50 percent more suicidal minors were reported. The numbers also rose in Zurich. At Pro Juventute, telephone inquiries for advice doubled last winter.
Well supplied in international comparison
Corona has now receded into the background. But now there is war in Europe. Tanks and bombs dominate the news, prices are rising, and with them worries about the future. The Pro Juventute organization writes of a “multi-crisis” on its website.
FSP Co-President Adler hears from school psychologists that they have never had so many acute and complex cases as now. ‘You are overwhelmed. We knew it would be difficult, but nobody expected the current situation.”
The demand for therapeutic help is huge. But what about the offer? During the pandemic, the media repeatedly reported that patients had been looking for therapists for months. The state of emergency hits an area in which, according to Warners, there was already a shortage – especially for the youngest in society. “Across Switzerland there is a lack of therapy places and psychotherapists specializing in children and young people,” writes Pro Juventute. Yvik Adler confirms: “It’s a disaster.”
Low earnings, no lobby
In an international comparison, Switzerland does not do badly when it comes to psychotherapeutic care, as the most recent study from 2017 shows. In Germany, extrapolated to full-time positions, there are 78 therapists for every 100,000 inhabitants. Half of these are psychiatrists and half are psychologists. The number of psychotherapists is similar in the Netherlands, 60 in Germany and only 36 in the UK.
Nevertheless, the Federal Office of Public Health stated even before the pandemic that the offer for children and young people was too scarce. Adler sees the lack of attractiveness of the profession as the reason for this: Hardly any other job is as stressful as caring for a child in acute need. In addition, there is little attraction for young medical professionals to go into psychiatry: it is one of the lowest-paying medical sectors.
Children and young people just don’t have an influential lobby, says Adler. The psychologist runs a practice in Solothurn. Child and adolescent psychiatry was closed in her canton. “No one understands, the clinic was always full. You couldn’t or didn’t want to afford them anymore.”
«Crack Seller Mentality»
Philipp Ramming is former President of the Swiss Association for Child and Adolescent Psychology. He says it bluntly: the area is completely underfunded, the lack of skilled workers is purely a question of power and money. With drastic consequences. «Having to wait six months for a treatment place is not justifiable in a child’s life. With major depression or anorexia, that means risking death.”
According to Ramming, all this happens under the pretext that psychotherapy is too expensive. That was a lie, says Ramming. With this argument, he always asks: “And how many millions of profits do the hospital groups make?” He goes even further and says that preventing therapies is profitable: “Untreated diseases in children lead to chronic diseases in adulthood, from which you can then make good money. It’s the mentality of the crack seller.”
But there are also counterexamples. Baselland and Zurich have expanded their range with funds from the cantons. Nevertheless, the situation is not completely relaxed, says Susanne Walitza, director of the Clinic for Child and Adolescent Psychiatry and Psychotherapy at the Psychiatric University Clinic in Zurich. For the future you have to be prepared “that we have more crises and that children and young people are always particularly affected”.
beds are not enough
As in many areas, the pandemic has accelerated change. In the Basel area, beds in the psychiatric ward that had been planned for a long time have already been set up. But it’s like the intensive care units, says Alain Di Gallo, director of the clinic for children and adolescents at the University Psychiatric Clinics in Basel: the staff is also needed. “Not only in the inpatient area, but also for lower-threshold offers in order to be able to intervene in good time and avoid hospitalization as far as possible.”
In this regard, outreach treatment in families and close cooperation with homes have proven very effective during the Corona crisis. The clinic can currently largely cover everyday life and treat the most urgent cases. “But we’re reaching our limits,” says Di Gallo.
The fact that there are too few psychiatrists is not only due to the relatively low wages compared to other doctors. According to Di Gallo, medical school needs to be made more attractive for psychiatry by better teaching the connection between the neurobiological and sociocultural aspects of the discipline. Many students with an interest in the psyche and its disorders are now more inclined towards psychology, says Di Gallo. But both are needed, psychiatrists and psychologists.
The current situation is as follows: The clinic can treat emergencies, but cannot offer longer-term therapy. This would have to take place on an outpatient basis with psychologists. But their practices are overcrowded. And vice versa, it is difficult to find a place for inpatient treatment in the case of a sharp crisis in a young person.
New model should help
Now new rules for psychological psychotherapists should improve the care situation. Previously, they were only allowed to bill their services through basic insurance if they were employed by a psychiatrist (delegation model). From July 1st, however, psychologists may work independently and treat patients for whom a doctor has prescribed treatment (scheduling model).
One reason for the lack of therapy places so far is the insufficient number of psychiatrists who have employed psychological psychotherapists. This bottleneck should now disappear, so the hope. There is untapped potential: to date, more than a quarter of psychological psychotherapists work exclusively with self-payers and those with additional insurance.
But the system change does not go through without a rumble. A few days before the start, the psychologists don’t even know how much they will earn. The reason for this is a rift in the health insurance industry. The two associations Santésuisse and Curafutura should have negotiated the new tariff for self-employed therapists together with the hospitals and psychologists. But Santésuisse withdrew from the negotiations – and thus annoyed the collective bargaining partners.
The psychologists’ association FSP demands that psychologists be allowed to charge the same amount for psychotherapy as psychiatrists, namely 190 francs per hour. After all, the psychologists would have gone through a similarly long training. And they would have to finance their own practice infrastructure in the future. Santésuisse thinks the demand is far too high – and only offered the previous tariff for delegated psychotherapists of CHF 135. “It doesn’t make sense to us why there should suddenly be significantly more pay for the same work,” says Santésuisse spokesman Matthias Müller.
Cantons decide on the tariff
That’s why the association didn’t want to know anything about the compromise that the rival association Curafutura had negotiated with the psychologists. This solution provides for compensation of CHF 155 per hour. The difference of 20 francs compared to Santésuisse’s proposal is likely to lead to additional costs of around 50 million francs per year – in addition to the 100 million francs that the model change will cost at least according to estimates by the Federal Council.
Because a large number of health insurers do not support the negotiated solution, the federal government cannot approve the tariff throughout Switzerland – the history of the blocked Tardoc doctor’s tariff is repeated. Each canton must now set the amount for the psychologists themselves. The Conference of Cantonal Health Directors (GDK) regrets this development – and has proposed to the cantons that they adopt the Curafutura-FSP compromise as a provisional measure for the next two and a half years.
This is intended to enable patients to access more psychotherapy places more quickly and prevent a patchwork of tariffs. The GDK assumes that most cantons will follow the recommendations. However, in many places the decision has not yet been made – for example in the canton of Zurich.