What forms of psychotherapy are there?

What a guideline procedure is

The term denotes a category in social insurance law. It means that the Federal Joint Committee, composed of representatives of the payers and providers responsible for health care in Germany, has admitted a procedure to the Psychotherapy Guideline and that the statutory health insurance system pays for the treatment.¹

The Guideline does raise a scientific claim in doing so: it requires of the recognized procedures a comprehensive theoretical system and evidence for the effectiveness of their treatment methods, and for the admission of a new procedure it additionally requires a recommendation from the Scientific Advisory Board on Psychotherapy together with proof of benefit.¹ Against what standard that claim was measured in any given case, however, depends on the year of admission. The section on chronology returns to this.

A further distinction is needed between the procedure as the Guideline defines it and the treatment practice within that procedure. The Guideline recognizes four procedures; which methods a psychotherapist actually applies within his own it prescribes only in outline. The overview that follows therefore also covers two variants that hold no category of their own but that matter considerably for the patient's choice.

For each guideline procedure the Guideline sets out how many hours may be authorized. By its own wording these allowances rest on therapeutic experience and describe the scope within which a successful outcome can as a rule be expected.¹

Behavior therapy

Behavior therapy understands mental disorders as learned behavior and unlearns that behavior through practice. It was not born in the consulting room but in the laboratory: out of Pavlov's conditioned reflex, Watson's program for a psychology without an inner life, and Skinner's account of reinforcement. It became a psychotherapy only after Hans Jürgen Eysenck denied the established procedures any proof of effectiveness in 1952 and Joseph Wolpe presented the first fully worked-out counter-model in 1958 with systematic desensitization. Its classical core is confrontation: the patient exposes himself to what he avoids and remains in the situation until the fear subsides of its own accord.

What the patient thinks while doing so went unregarded in the classical version — not out of negligence but by design: Watson's black box stayed shut. The Psychotherapy Guideline abandoned that narrowness long ago. It expressly counts cognitive, emotional, motivational, and physiological processes as part of «behavior», and it lists cognitive restructuring among the principal forms of intervention.¹ What actually happens in an individual course of treatment the Guideline does not regulate.

Of all forms of psychotherapy, behavior therapy commands the broadest base of controlled studies; the evidence is strongest for circumscribed disorders. It was admitted to the Psychotherapy Guideline in 1987, twenty years after the psychoanalytically grounded procedures.²

In detail: What is behavior therapy?

Cognitive behavioral therapy

Cognitive behavioral therapy is behavior therapy extended by work on thinking. It combines two steps: correcting faulty patterns of thought, and then practicing the changed behavior together with the psychotherapist. It arose in the 1960s, when Aaron T. Beck and Albert Ellis added the cognitive element to behaviorism — the so-called cognitive turn. It holds no category of its own in the Psychotherapy Guideline; it is billed as behavior therapy, and official patient information uses the two labels largely interchangeably. In effectiveness research it forms a single group with classical behavior therapy, and that group is regarded as the best documented of all.

How much work on thinking a treatment described as cognitive behavioral therapy actually contains is another matter: the proportion varies widely, and the label alone says nothing about it.

In detail: What is cognitive behavioral therapy?

Cognitive psychotherapy

Cognitive psychotherapy treats psychological suffering exclusively through the correction of faulty patterns of thought. It holds that events do not produce anxiety or depression; the judgments passed on them do — an idea already found in Epictetus, and one that Aaron T. Beck was the first to document empirically in the early 1960s.

Unlike cognitive behavioral therapy, cognitive psychotherapy needs no behavioral training led by the psychotherapist: a patient who has corrected, with therapeutic help, the self-defeating thinking and the distorted cognitions that caused his suffering changes his behavior without further guidance. It too is not a category of its own under the Guideline and is billed as behavior therapy. In effectiveness research it appears within the cognitive-behavioral group; as a separate condition tested against cognitive behavioral therapy it has rarely been examined. The findings for the group therefore cannot be applied to it alone without qualification.

In detail: What is cognitive psychotherapy?

Person-centered psychotherapy

Person-centered psychotherapy holds that a person already possesses the means of his own change and unfolds them within a particular kind of relationship. Carl Rogers named three conditions: unconditional positive regard, congruence, and empathic understanding. The therapist neither interprets nor instructs; he accompanies the client's self-exploration.

In Germany it is not a guideline procedure. In 2006 the Federal Joint Committee found that effectiveness and benefit were not documented with sufficient breadth for the most significant psychological illnesses³; an indication of benefit emerged only for affective disorders.⁴ It was the first time that a form of psychotherapy in Germany had been assessed by the criteria of evidence-based medicine.

The professional-law dimension is to be distinguished from this: the Scientific Advisory Board on Psychotherapy has granted person-centered psychotherapy scientific recognition for the treatment of adults.⁵ Scientific recognition and insurance approval thus diverge here — a circumstance that played the decisive part in the suits brought by the psychotherapists concerned. The Federal Social Court nonetheless upheld the decision of the Federal Joint Committee in 2009, allowing only that insured persons might have a claim as a matter of benefits law.⁶

Systemic therapy

Systemic therapy regards a disorder not as a property of a person but as an expression of the relationships in which that person lives. It emerged in the 1950s and 1960s out of family therapy and cybernetics. The work is often done in a multi-person setting, with circular questioning, reframing, and a deliberate search for exceptions to the problem behavior; the question is not what caused the pattern but what sustains it. The Scientific Advisory Board on Psychotherapy granted it recognition under professional law in 2008⁷, the Federal Joint Committee in 2019; since 2020 it has been the fourth guideline procedure for adults — and the only one to enter the system of care by the criteria of evidence-based medicine. For children and adolescents admission followed in January 2024; since July 1, 2024, it has been an insurance benefit there as well.⁸ At 36 hours, and 48 at the second step, its allowance is the smallest of the four procedures.⁹

Psychodynamic psychotherapy

Psychodynamic psychotherapy — in German tiefenpsychologisch fundierte Psychotherapie — derives from psychoanalysis but confines itself to a circumscribed present conflict. Its development in Germany owes much to Annemarie Dührssen, who also pressed for the admission of psychotherapy to insurance coverage. The work is done seated and in conversation, once or twice a week; transference is attended to but not placed at the center, and the treatment goal is fixed in advance. It has belonged to the guideline procedures since 1967 and is today, alongside behavior therapy, the most widely practiced procedure in outpatient care. Controlled effectiveness studies exist; their number falls short of those for behavior therapy. It has never undergone assessment by the criteria of evidence-based medicine.

Psychoanalysis (psychoanalytic therapy)

Psychoanalysis treats psychological suffering as the expression of unconscious conflicts that are inaccessible to consciousness and that resurface in the relationship with the analyst. It goes back to Sigmund Freud and is the oldest of the procedures billable today. The work proceeds by free association and interpretation; the patient says whatever occurs to him, and the analyst interprets the patterns in it, above all the transference. The aim is not the removal of a symptom but a structural change in the personality — which is why the procedure is by far the longest: the Guideline provides for up to 300 hours, at up to three sessions a week. Controlled effectiveness studies exist; their number is the smallest among the four guideline procedures. Its status does not rest on an assessment by the criteria of evidence-based medicine; it has been in the Guideline since 1967.¹⁰

The seven procedures compared

Procedure	Statutory insurance, Germany	Base of studies
Behavior therapy	since 1987 up to 80 hours	broadest
Cognitive behavioral therapy	billed as behavior therapy	broadest (as the behavior therapy group)
Cognitive psychotherapy	billed as behavior therapy	documented within the behavior therapy group
Person-centered psychotherapy	not recognized	assessed in 2006, rejected
Systemic therapy	since 2020 up to 48 hours	assessed, admitted
Psychodynamic psychotherapy	since 1967 up to 100 hours	narrower than behavior therapy
Psychoanalysis	since 1967 up to 300 hours	narrowest

The figures give the maximum allowance for adults in individual therapy. It is authorized in two steps: behavior therapy up to 60, then up to 80; psychodynamic psychotherapy up to 60, then up to 100; psychoanalytic therapy up to 160, then up to 300; systemic therapy up to 36, then up to 48. Alongside these, all four procedures offer a short-term therapy of up to twice twelve hours. It is not a stage that precedes long-term therapy: once the trial sessions are complete, an application for long-term therapy may be filed directly.⁹

Why the allowances differ so widely

The chronology answers the question better than any discussion could.

1967 psychodynamic and psychoanalytic psychotherapy enter insurance coverage.¹⁰ The criteria of evidence-based medicine do not yet exist.

1987 behavior therapy follows.²

2006 person-centered psychotherapy is rejected — the first application of the criteria of evidence-based medicine.³

2008 the Federal Joint Committee commits itself to subjecting the procedures already admitted to the same assessment.

2019 it discontinues that undertaking. The stated ground is a ruling of the Federal Social Court to the effect that the guideline procedures require no fresh justification as to quality and effectiveness.¹¹

2020 systemic therapy is admitted — after assessment, with the smallest allowance of the four.

Of the seven procedures described here, then, exactly two have undergone assessment by the criteria of evidence-based medicine. One was rejected, one admitted. The three procedures with the largest hour allowances are not among them.

And in Switzerland?

Since the physician-referral model of 2022, Switzerland has known no procedure-specific allowances of this kind. Psychotherapy provided by federally recognized psychotherapists is covered by basic insurance on a physician's referral, initially for fifteen sessions, with the possibility of extension. The question of procedure is thus left largely to the agreement between patient and therapist — which makes the choice freer and leaves responsibility for it entirely with the patient.

Assessment by the editors of Psychotherapie.com

What has been described up to this point is what has been officially decreed. What follows is an opinion — the clinical observation of the author.

Read the table from top to bottom and a relationship appears that no one has to assert: the procedure with the broadest base of studies receives eighty hours, the one with the narrowest three hundred. One may take this for coincidence. One may also take it for the expression of an order that arose before evidence-based medicine and was never overtaken by it. I hold the second to be correct. This view would be refuted by a demonstration that the allowances follow from treatment need and not from the date of entry into the Guideline.

Nor are the eighty hours of behavior therapy a measure of what the individual patient needs. The Guideline rests the allowances on therapeutic experience — that is, on the same source of knowledge that was available in 1967 and that today would no longer suffice for the admission of a new procedure. Britain's National Institute for Health and Care Excellence puts the total requirement in panic disorder at seven to fourteen hours.¹² The two figures answer different questions — and precisely there lies the trap: a reader of the German table learns what he is entitled to, not what his treatment requires. The upper limit then becomes an expectation, and the expectation keeps him in treatment longer than would be necessary.

There remains the group on which the proof of effectiveness rests. It is not uniform within itself: under «cognitive-behavioral procedures» are gathered treatments that almost exclusively practice behavior and treatments that almost exclusively work on thinking. The Guideline expressly requires the work on thinking; in my clinical observation it frequently takes place, in practice, only at the margins. Aaron T. Beck recorded the same finding in his foreword to his daughter's textbook: the practice of the method, he wrote, is by no means simple, and too many mental health professionals call themselves cognitive behavioral therapists without possessing even the most basic conceptual and treatment skills.¹³

Which of the two treatments he is receiving is something the patient rarely learns before it begins. One simple question carries further, because it reduces the difference to what it comes down to: do I wish to be treated like Pavlov's dog, whose reaction is reconditioned — or like a human being who recognizes an error in his own thinking and changes his behavior accordingly, unaided? Both are psychotherapy. Only the second presupposes that I am credited with the ability to think — and that I am genuinely willing to take the effort of thinking¹⁴ upon myself.

What that difference consists of in detail is set out in: Cognitive Behavioral Therapy and Cognitive Psychotherapy — The Difference.¹⁵

Declaration of interest: The author is a psychotherapist with decades of experience within the statutory health insurance system; he offers cognitive psychotherapy and therefore has a commercial interest in the position argued above. His anxiety clinic treats in an average of ten hours, which Der Tagesspiegel described as «efficient».¹⁶ Both are to be taken into account in reading the assessment above. The descriptive sections of this page rest on the official documents and publications listed below and are verifiable independently of that assessment.

Frequently asked questions about forms of psychotherapy

Which forms of psychotherapy does health insurance pay for?

In Germany four: behavior therapy, psychodynamic psychotherapy, psychoanalytic therapy, and systemic therapy. In Switzerland it is not the procedure that decides but the physician's referral.

Which form of psychotherapy is the most effective?

That depends on the disorder. For anxiety disorders and depression several procedures count as effective; the base of studies for the cognitive-behavioral procedures is the broadest. The large meta-analysis by Klaus Grawe arrives at the finding that «cognitive-behavioral» psychotherapy is «on average highly significantly more effective than psychoanalytic therapy and person-centered psychotherapy».¹⁷ The finding holds for the group, not for every individual treatment within it. The more consequential difference in practice lies less in effectiveness than in the effort a successful outcome requires.

How long does psychotherapy take?

Between a few hours and several years, depending on the procedure. The allowances of the Psychotherapy Guideline range from 48 hours for systemic therapy to 300 hours for psychoanalytic therapy.⁹ These are upper limits, not standard durations. By the standard of Britain's National Institute for Health and Care Excellence, panic disorder requires no more than seven to fourteen therapy hours.¹²

Why is person-centered psychotherapy not an insurance benefit?

In 2006 the Federal Joint Committee concluded that its effectiveness was not documented with sufficient breadth for the most significant psychological illnesses.³ The Federal Social Court upheld that decision in 2009.⁶ To be distinguished from this is recognition under professional law: the Scientific Advisory Board on Psychotherapy has granted the procedure scientific recognition for the treatment of adults.⁵ Training in it remains possible.

What is the difference between behavior therapy and psychoanalysis?

Behavior therapy changes behavior through practice and does not ask after the cause. Psychoanalysis looks for the cause in the unconscious and works by interpretation. The one is designed for weeks to months, the other for years.

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