1,500 psychologists will soon be unemployed, say three of those affected

For ten years, psychologists have been fighting for their therapies to be billed through basic insurance.

Until now, they had to be employed by a psychiatrist – a ‘medical goddess’, so to speak. Those who worked independently were not allowed to declare their services via the basic insurance, so the patients paid themselves.

In March of this year, the Federal Council decided to change this and introduced the so-called arrangement model on 1 July 2022 with a transitional phase until the end of the year. This should guarantee the population better access to mental health care – and is now doing the opposite.

There are two reasons for this: Firstly, some basic insurance companies no longer want to reimburse the services of therapists in training. As of January, there are 1,500 psychologists without a job and 10,000 patients without a place in therapy. This is according to estimates by the Federation of Swiss Psychologists (FSP).

Second, the arrangement model now stipulates that therapists undergoing advanced training must complete an additional year in an outpatient clinic or hospital recognized by the Swiss Institute for Continuing Medical Education (SIWF). But there are hardly any such places.

Marie Fournier* was at the unemployment office. She is 39, has two children and a doctorate in psychology. She is still studying to be a psychotherapist and says: “It’s a bad situation. I can’t say it any other way.”

Fournier spent the past year applying for positions in hospitals recognized by the Swiss Institute for Medical Continuing Education (SIWF). She got the last rejection three days ago. Although she meets all the criteria and sends two letters of recommendation, she is not even invited. She says, “It’s disheartening. I’m doing my very best and not getting an interview. I don’t know what else to do.”

Fournier works in two private practices in Lausanne and Sion, where she treats five patients between the ages of 19 and 46. Before the new scheme, there were twice as many and five more on the waiting list. Now she only cares for those who could not do without therapy and who need to be treated with medication. The diagnoses range from anxiety and eating disorders to bipolarity.

She says: “Transfers to colleagues are unrealistic. They are all fully booked.” Since Fournier is still in training, she will no longer be allowed to treat her patients from January – even if they pay for the therapy themselves.

Says Fournier, “It seems like the state hasn’t considered whether such a change can be made so quickly. Well, it hasn’t.”

Fournier has to apply for unemployment benefits before the new year. Whether she is entitled to this as a self-employed person will be seen on December 29 at 8 a.m. Then your next appointment is at the unemployment office.

It is the health insurance funds of the association Santésuisse, in which about half of the Swiss population is insured, that will no longer pay for therapies from 2023. The reason: the legal basis is missing.

The FSP sees it differently. In August 2022, the Federal Council responded to an interpellation by SP national councilor Franziska Roth: “If a service was provided by a person in further training, it is deemed to have been provided by the person entrusted with supervision. The organisation […] bears the responsibility for this and calculates on behalf of [Grundversicherung] away.”

The FSP clearly reads from this that the benefits of people who follow further education simply remain in the basic insurance. However, because the insurers see this differently, the FSP asked the Federal Public Service of Public Health (BAG) to explicitly write this in the regulation.

But the BAG stays out of it. In a statement, the Bundesamt writes to Watson that the service providers and the insurers must clarify this among themselves. Is the BAG concerned about setting a precedent with a clear announcement that could also affect the status of other service providers in the health system? The rule that the services of people in training are paid for from the basic insurance also applies to future doctors, among other things.

Why insurers suddenly want to treat psychologists in training differently can only be guessed at. Santésuisse left a request from Watson unanswered at the time of publication.

The topic has now entered politics. SP National Councilor Franziska Roth wants – together with other political representatives – to seek talks with Santésuisse in the new year.

Santésuisse and the FOPH proposed to extend the transition phase until the end of 2023.

The FSP was against. In a statement, she writes that the problem would only have been delayed and exacerbated. In a year’s time, only more people in secondary education would be without a solution. In addition, the functions had already ended in the summer. Under these circumstances, “the late extension” would have yielded little.

Emilie Martin* regrets the decision of the FSP: “If the rules are changed, they must also be adapted to the circumstances. In this case, that would have meant that the transition phase lasted longer than half a year.”

Martin is 39 and a psychoanalyst in training. The only thing missing from her diploma is her thesis. She has eight years of work experience and has treated 400 patients in 7,000 hours of therapy.

In the new year, she will be out of a job and her 60 patients will no longer have a therapist – a prospect that creates a lot of uncertainty.

To become a psychotherapist, you must study for five years to earn a master’s degree and then take another five years of further training, which costs between CHF 35,000 and CHF 90,000, according to the FSP.

According to the University of Zurich, you must complete 53 continuing education courses, do 200 hours of supervision, 100 hours of therapy yourself, and 500 hours of therapeutic work and two years of clinical practice at a 100 percent workload.

Martin says: “It is an insult that, after all your efforts as a therapist, you are still not allowed to claim for basic insurance.”

The problem is the extra year in an outpatient clinic or hospital recognized by the SIWF. The FSP wrote in a statement in November: “The number of training places available at the SIWF institutes is currently not sufficient to meet the increased demand resulting from the model change.”

Psychologists in training are therefore awarded the title of therapist after ten years, but are not allowed to claim via the basic insurance because they have not (yet) completed the SIWF year.

According to a survey by the GIRT (Association of Cantonal Associations of Psychologists in French-speaking Switzerland and Ticino), 58 percent of trainee psychologists in French-speaking Switzerland and Ticino are affected by this scenario. Many of them work in private practices not recognized by the SIWF.

In German-speaking Switzerland there are more accepted training places in hospitals and outpatient clinics, but if settlement via the basic insurance is not guaranteed, there is also a problem there. According to the FSP, 30 to 50 percent of psychotherapists in Swiss hospitals are trainees.

Martin spent four years working in psychiatric clinics in Lausanne, Montreux and Vevey, where she says she came into contact with the most serious cases in the canton of Vaud – the so-called “patates chaudes”, the cases that no one wants to assume. But this experience is not recognized by the SIWF.

Now she is applying for SIWF positions, also outside the canton, and she only gets rejections. She says, “I’m probably too experienced and too expensive.” Martin has already complained to the BAG and the FSP. Now she also wants to write to Vaud canton doctor Karim Boubaker, SP state councilor Rebecca Ruiz and responsible SP federal councilor Alain Berset.

Other psychologists have also become active and have started a petition. Your position: Young psychotherapists are systemically important.

Alice Dubois* is in the same situation. She is 30, a psychologist by training and works in private practice in Geneva. Despite completing her education, she has to resign from her position at the end of the year. Last week she had to tell her 40 patients that from 2023 she will no longer be allowed to declare a bill with the basic insurance.

Dubois took her title in October – but she has to add the SIWF year to that. Because the regulation model states that everyone who receives his title after 1 July 2022 must do the extra year.

The FSP then asked the BAG to adjust this rule: anyone who had already registered for further training before the decision of the Federal Council of 19 March 2022 should also be able to complete it according to the old model. According to the FSP, this would have immediately alleviated the work situation. The BAG refused.

This is inexplicable to Dubois: “If there is a new curriculum at the university, everyone who started the old one can also finish it. I don’t understand why that isn’t the case here. This would have given the system more time to adapt to the new demands – and to create jobs.”

Because some of the jobs she needs to look for now haven’t been created yet. The SIWF is aimed at training doctors – not psychologists.

Although Dubois has been unemployed since January, she is particularly concerned about the future of her patients between the ages of 17 and 73 who are in therapy with her for eating disorders, depression, anxiety disorders or trauma.

Not being able to declare via the basic insurance means for her patients to stop therapy. Many of them couldn’t imagine going on without her, says Dubois, and some have been with her for five years. The fear of relapse due to discontinuation of therapy is high among patients. Dubois says, “At least two are suicidal.”

The concern of not being able to find an alternative therapy site is also very present among the patients. Du-bois says: “I’m trying to find a replacement for everyone by January. But it’s very difficult.”

According to the FSP, tens of thousands of people in Switzerland did not receive psychotherapeutic treatment last year because there was a massive lack of basic insurance-funded therapy places. With the transition to the package model, another 10,000 patients will now be added.

*Names changed by editors