International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Group Psychotherapy in Germany Rainer Weber Ph.D. & Bernhard Strauss Ph.D. To cite this article: Rainer Weber Ph.D. & Bernhard Strauss Ph.D. (2015) Group Psychotherapy in Germany, International Journal of Group Psychotherapy, 65:4, 513-525 To link to this article: http://dx.doi.org/10.1521/ijgp.2015.65.4.513
Published online: 19 Oct 2015.
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Date: 25 February 2016, At: 07:41
INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 65 (4) 2015 WEBER AND STRAUSS GROUP PSYCHOTHERAPY IN GERMANY
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Group Psychotherapy in Germany RAINER WEBER, PH.D. BERNHARD STRAUSS, PH.D.
ABSTRACT This article gives an overview of the development of group psychotherapies in Germany originating from a psychodynamic tradition. The German health system provides access to inpatient and outpatient psychotherapy for all of its citizens. Whereas groups are common in inpatient settings, the provision of outpatient group treatment still could be improved, as it is the case for the general training of group psychotherapists. Group research in Germany largely reflects clinical practice, with more studies coming from the inpatient field. It is stated that the general image of group treatment seems to be largely positive, which could provide a basis for political initiatives to improve the dissemination of group therapy in this country. HISTORICAL AND THEORETICAL BACKGROUND
T
here is no doubt that psychoanalytical theory in the tradition of Sigmund Freud and his successors dominated the development of both psychotherapy and group psychotherapy from the beginning of the 20th century. S. H. Foulkes (Siegismund Heinrich Fuchs), one of the founders of group analysis and the European group movement, studied medicine in Heidelberg, Munich, and Frankfurt. He completed his psychoanalytical training in Vienna. Rainer Weber is affiliated with the Clinic for Psychosomatics and Psychotherapy, University Hospital of Köln, Germany. Bernhard Strauss is affiliated with Jena University Hospital, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany.
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Later, in 1931 he acted as medical director of a psychiatric unit associated with the Frankfurt psychoanalytic institute. During his work in Frankfurt, he was strongly influenced by representatives of Gestalt psychology as well as the “Frankfurt School” of philosophy. In 1933, Foulkes emigrated to London following an invitation of Ernest Jones and became a lecturer and training analyst at the London Psychoanalytic Institute. In 1942, he started to work with groups after being posted to the Military Neurosis Centre at Northfield. After WWII, the small German psychoanalytic community struggled to regain recognition in the international psychoanalytic world. There are several reasons why group psychotherapy came (back) to Germany after the terror of the Nazi regime that caused a dramatic splitting of the local professional group of colleagues and isolation from the international community (Hermanns, 2009). In 1947, Foulkes presented his ideas on group therapy at an international conference on psychoanalysis (title of his talk: Group Psychotherapy and the Future of Our Culture) in Amsterdam. There was great debate about whether or not German psychoanalysts should be invited to this conference (Herrmanns, 2009). In August 1948, the 3rd International Conference on Mental Health took place in London with more than 2,500 participants from 50 different countries, including a small delegation from Germany. Group therapy was one of the major topics of the conference. Bion presented his work on groups. It is important to note that historically group therapy in Germany has primarily developed in inpatient settings (see below). Group therapy was selectively applied in some of the existing university hospitals (e.g., Tübingen, Freiburg, Giessen), initiated by medical directors who came in touch with practicing group therapists in the U.K. and the United States (Hermanns, 2009). Another important impulse for the development of group therapy in Germany came from the Lindauer Psychotherapiewochen (Lindau Psychotherapy Weeks), a conference founded in 1950 (and in its 65th year of existence with nearly 4,000 participating therapists every year) that provides continuing education for practitioners. In 1960, the major topic of the conference was psychotherapy in groups with Foulkes, Raoul Schindler, Walter
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Schindler, and Raymond Battegay as presenters and/or workshop leaders. As a consequence of these early initiatives, several group analytic training sites were developed under the auspices of the Institute of Group Analysis (IGA), for example, Altaussee (Austria), Heidelberg, and Münster. One of these initiatives was the group analysis seminars (GRAS) founded by Michael Lukas Moeller, who organized block trainings in group analysis by inviting several German-speaking British members of the IGA to serve as trainers and provide a Foulkesian form of group analysis. In 1960, Alexander Mitscherlich founded the Institute for Psychoanalysis and Pychosomatics, where group therapy played a significant role in the delivery of psychotherapeutic treatment. This institute, later renamed the Sigmund Freud Institute, favored Bion’s theory and the Tavistock tradition (Hermanns, 2009). Hermann Argelander was one of the leading individuals in Frankfurt, developing a specific approach to group analysis combining influences from Balint, Bion, and the Tavistock group. A third important tradition within the spectrum of psychodynamic group psychotherapy includes Annelise Heigl-Evers and her husband Franz Heigl as doyens of the development of group therapy in Germany. They founded Tiefenbrunn, a hospital for psychosomatic medicine and psychotherapy that became the cradle of the so-called Göttinger Modell (Göttinger model). This approach is associated with the theories of Foulkes, but also group dynamics, the philosophy of Hannah Arendt, and theme-centered interaction (TCI) developed by Ruth Cohn. One of its core features is the differentiation of the group approach according to the structural maturity level of the group members. Classical group analysis was for the most mature patients; more focused psychodynamic group was for patients with milder structural impairment, and psychodynamic-interactional group therapy was for patients with more severe mental problems and personality disorders (Staats, Dally, & Bolm, 2014). East Germany, an independent state between 1949 and 1990, was not only separated by the Berlin Wall erected in 1961, but also isolated from the dominant psychotherapeutic approaches of the time. Group therapy became the major treatment approach in the German Democratic Republic (GDR). Unlike in Western Europe, there was no unbroken psychoanalytical tradition. Psy-
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choanalysis was officially banned in the communist health care system. One of the leading psychotherapists in the GDR was Kurt Höck (1920–2008), a medical doctor and trained psychoanalyst. He formed the so-called Intendierte Dynamische Gruppentherapie (intended dynamic group psychotherapy) as a unique school of group psychotherapy that was strongly influenced by the theory of Kurt Lewin (Seidler, 2006). He also founded the hospital Berlin-Hirschgarten, which served as a model for group-oriented inpatient psychotherapy in the GDR. Another milestone in the development of group psychotherapy in Germany dates back to 1967: A group of therapists oriented toward psychoanalysis and group dynamics founded the Deutsche Arbeitskreis für Gruppenpsychotherapie und Gruppendynamik (DAGG; German Consortium of Group Psychotherapy and Group Dynamics). For many years, the DAGG was the professional association for psychoanalytic, group dynamically oriented, and psychodrama group psychotherapists in Germany. After intense internal conflict, the association dissolved in 2011. Members of the most influential section of the DAGG (the group analytic section) founded the Deutsche Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G; German Society for Group Analysis and Group Psychotherapy) in 2012. Within the DAGG, the psychodrama section was influential, representing an alternative group approach to group analysis. Since the 1970s, other group models spread through Germany. With a focus in Hamburg, client-centered group psychotherapy was cultivated by Reinhard and Annemarie Tausch, and largely influenced by Irving Yalom. Their attempt to publicly demonstrate group psychotherapy via television is still legendary. Between 1978 and 1980, they were responsible for a regular “life transmission” of client-centered groups (Psychotreff) on regional television. Parallel with the development of humanistic approaches, behavior therapists began to apply their treatment to group settings. One pioneer was Klaus Grawe (1945–2003), later a wellknown psychotherapy researcher, who, with Jochen Eckert and Nick Becker, chaired an inpatient unit providing parallel psychodynamic, humanistic, and behavioral group treatment for psychiatric patients at Hamburg University Hospital (Eckert & Bier-
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Table 1. Time Allocations for Group Therapy in Insurance-Covered Outpatient Care Psychodynamic
Psychoanalytic
CBT
Individual therapy (50 min. sessions)
Up to 80 [100]* sessions
Up to 240 [300]* sessions
Up to 60 [80] sessions
Group therapy with adults (100 min. sessions)
40–60 [80]* sessions
60–120 [150] sessions
Up to 80 sessions (individual and/or group sessions of 50 min. duration)
Children/adolescents
40–60 sessions (100 min.)
40–60 sessions (100 min.)
45–60 sessions (individual and/or group sessions of 50 min. duration)
*Absolute maximum, has to be justified.
mann-Ratjen, 1985). In 1980, Grawe edited the first textbook, Behavior Therapy in Groups (Grawe, 1980), establishing another important group tradition in the German health care system that has become increasingly important. THE ROLE OF GROUP THERAPY IN THE GERMAN HEALTH CARE SYSTEM
Statutory health insurance is a major pillar of the German health care system, meaning that almost every citizen (approximately 90%) is insured against costs of illness; approximately 10% use private health insurance. Psychotherapy has been covered by the health insurance system since 1967. Outpatient psychotherapy is regulated by a continuously revised law, the Psychotherapierichtlinien (psychotherapy rules), which includes psychoanalytic, psychodynamic, and cognitive behavioral therapy; they are all now thought to have demonstrated their scientific effectiveness. Other psychotherapeutic approaches are currently not covered by insurance. Group therapy allocations within outpatient treatment are summarized in Table 1. For each patient in individual and group therapy, psychotherapists are required to write a report that is anonymously evaluated by an independent reviewer. This procedure is thought to ensure quality by establishing the medical necessity for treatment, the treatment plan, and the allocation of insurance money. In 2010, the German Association of Psychotherapists (Deutsche Psychotherapeutenvereinigung; DPTV) organized a survey among German therapists working in private practice
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(Walendzik et al., 2011). It revealed that 24.2% of all therapists possessed a license to work with groups (for training guidelines in group therapy, see below), but only about one-third currently provide groups in their therapeutic work. Asked about reasons for this discrepancy, the therapists primarily reported administrative issues, for example, writing case reports for each patient and difficulties in establishing a group. Interestingly, therapists in rural areas were more actively running groups, probably due to the pressures of supply and demand. One specific feature of the German health care system is the prevalence of a large number of hospital beds for patients needing inpatient psychotherapy and psychosomatic care. In 2004, German hospitals covered 122 special units for psychosomatic medicine and psychotherapy, with more than 4,412 inpatient beds (Barghaan, Schulz, Koch, & Watzke, 2009). In addition, hospitals specialized for psychosomatic inpatient rehabilitation cover almost 25,000 beds (Linden, 2014). In most of these hospitals, group therapy is the treatment of choice, usually as an adjunct to other treatment approaches, such as art therapy, creative and body-oriented treatments, occupational therapy, and so forth. TRAINING IN GROUP THERAPY
In the German health care system, psychotherapists need specific qualifications to obtain the license for billing group treatment to insurance companies (Mattke & Strauss, 2012). Currently, in order to work with groups in private practice, professionals are required to have training in individual therapy, either as a psychologist or as a medical doctor, plus the following additional requirements related to their primary therapeutic orientation (i.e., psychodynamic, psychoanalytic, or cognitive-behavioral): • 40 sessions (90–100 min.) personal therapy in a group • 48 hours theoretical training (group theory and group dynamics) • 60 hours group therapy under supervision (with a minimum of 40 sessions supervision)
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Membership in a group psychotherapeutic society (optional) requires more advanced training, including more hours of theory and personal therapy as well as group psychotherapeutic practice The situation for those practicing group therapy within hospitals is completely different. There, it is more often the rule that groups are directed by psychologists or medical doctors with no experience or specific training or education in group therapy (Strauss et al., 2012). Accordingly, a number of initiatives are in place directed towards providing time-limited and focused training for therapists working in institutions with psychotherapeutic inpatient and/or day treatment (e.g., Mattke & Strauss, 2012). GROUP THERAPY AND RESEARCH IN GERMANY
Bridging the gap between group psychotherapy research and practice is a constant challenge. In order to achieve a meaningful synthesis of research and practice, scientists must focus on issues that practitioners identify as important and useful. Ogrodnizcuk, Joyce, Lau, and Sochting (2010) published a survey of Canadian Group Psychotherapy Association members’ perceptions of psychotherapy research. The objective of the survey was to identify research topics and issues important to group psychotherapists. Due to the uniqueness of the German service delivery model, Weber, Ogrodnizcuk, Schultz-Venrath, and Strauss (2012) carried out a parallel study in Germany among members of the Germany Society for Group Analysis and Group Psychotherapy (D3G). Surprisingly, there were no significant differences between the German and Canadian samples regarding the main topics; similar limitations of current research were reported. Many respondents thought that research would distort or even interrupt the therapeutic process. They indicated a lack of qualitative and single case-study research designs and an overemphasis on randomized controlled trial (RCT) studies. A large proportion of both samples believed that researchers should focus on the study of relationship variables instead of specific treatment techniques, and that research results should be communicated in a more “digestible” way. When asked about research areas that would be
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important in the future, understanding group processes, group leaders’ behavior, and cost-effectiveness issues were commonly mentioned. During the past decades, there has been some group psychotherapy research. However, RCT studies were primarily limited to CBT (e.g., Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003). Within the outpatient field, the so-called PAGE-Studie (Tschuschke, Anbeh, & Kiencke, 2007) provides the only huge naturalistic group therapy study in Germany. The authors conducted a process-outcome study with three forms of group treatment: psychoanalytic, psychodynamic, and psychodrama. Primarily, the authors were interested in describing changes in psychological symptoms, interpersonal problems, therapy goals, and global assessment of functioning. The sample consisted of 40 therapists who had treated more than 600 patients. The results of the study underline the general effectiveness of outpatient group therapy without supporting interpretations of the efficacy of specific treatments. Consistent with the dominance of inpatient group treatments in Germany, studies in effectiveness and process research in inpatient settings prevailed. Some studies tried to reflect the complexity of inpatient group work, for example, the Hamburg study of inpatient group therapy (Eckert & Biermann-Ratjen, 1985), the Heidelberg Follow-up Project (von Rad, Senf, & Bräutigam, 1998), the Stuttgart Group Therapy Study (Tschuschke, 1993), and the Kiel Group Therapy Study (Strauss & Burgmeier-Lohse, 1994). Bernhard Strauss and Jochen Eckert founded a research network for inpatient group research in 1989 with members from university as well as general and rehabilitation hospitals. Within this network, several studies addressed the question of whether interpersonal problems and/or attachment characteristics serve as predictors for treatment outcome and therapeutic factors in inpatient group treatment (e.g., Davies-Osterkamp, Strauss, & Schmitz, 1996; Strauss et al., 2006). Some German researchers have always had close working relationships with their North American colleagues (e.g., Volker Tschuschke with Robert Dies and K. Roy MacKenzie). During the past two decades, the research group in Jena had a fruitful collab-
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oration with Gary Burlingame and his group at Brigham Young University (BYU), resulting in comprehensive reviews of the research literature (e.g., Burlingame, Strauss, & Joyce, 2014) and in the collection (AGPA Core Battery; Strauss, Burlingame, & Bormann, 2008) and adaptation of measures for group research, for example, the Group Readiness Scale and the Group Questionnaire (Bormann, Burlingame, & Strauss, 2011; Löffler, Bormann, Burlingame, & Strauss, 2007). In addition to a large number of texts related to group psychotherapy and group dynamics, the journal Gruppenpsychotherapie und Gruppendynamik has been important as a vehicle for theoretical and research articles on group issues for more than 50 years. The research literature comprises conceptual work, such as the development and application of specific treatment models and studies validating research measures as well as process and outcome studies such as those mentioned above. UNIQUE ISSUES RELATED TO GROUP THERAPY IN GERMANY
The anchoring of psychotherapy as a standard insurance benefit in the health care system and the huge number of hospitals providing group psychotherapy are probably unique features of group treatment in Germany. While the psychodynamic tradition had an enormous influence on psychotherapy in Germany, humanistic and, increasingly, CBT–related approaches are also important sources of group training and research (e.g., Sipos & Schweiger, 2013). THE FUTURE OF GROUP WORK IN GERMANY
The development of group psychotherapy in Germany is strongly connected to the role of psychoanalysis in Europe before, during, and after World War II. As in many other Western countries, group methods experienced a surge of interest following the student protests of the late 1960s. Horst Eberhard Richter (1972) published a popular book on how groups might assist in the proliferation of high social and moral expectations of others and the hope that a group culture could contribute to societal change and assist in overcoming the Nazi period. During the 1970s and
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1980s, groups were popular in many fields inside and outside the health care system. Recently, several authors from sociology and/or psychoanalysis (e.g., Hirsch, 2004; Koenig, 2011) argued that groups have lost their attractiveness and importance over the past two or three decades, reflecting diminished expectations, an increased tendency to withdraw from social interaction, and a decline of “social capital” (Putnam, 1995). A more recent study addressed people’s group-related attitudes and experiences (Strauss, Spangenberg, Brähler, & Bormann, 2015). It revealed a surprisingly positive picture of attitudes towards and expectations with groups in general, and psychotherapy groups in particular. At least 6% of a representative sample of more than 2,500 individuals revealed experiences with group psychotherapy, underscoring the status of groups within the health care system. Yet, from a health care service perspective, there is still a discrepancy between the (low) number of psychotherapists offering group treatment and the waiting time until individuals begin outpatient psychotherapy. Accordingly, the current government of Germany, consisting of a coalition of three political parties, has decided to include a position in their coalition agreement stating that psychotherapeutic outpatient service must be improved, and that “the provision of group psychotherapy should be supported.” This is the first time that health care politics have actively promoted group psychotherapy. The coalition declaration may be accompanied by specific actions, such as omission of the required case reports and an increase in the honorarium paid to clinicians providing group intervention. If successful, these actions could well form the basis for improving access to group treatment in Germany and other countries.
REFERENCES Barghaan, D., Schulz, H., Koch, U., & Watzke, B. (2009). Versorgungsstrukturen im stationären Setting in Deutschland. Verteilung von Einzel- und Gruppentherapie und deren psychotherapeutischen Ausrichtungen [Supply structures in an inpatient setting in Germany. Distribution of individual and group therapy and their psycho-
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therapeutic orientations]. Gruppenpsychotherapie und Gruppendynamik, 48, 83-103. Bormann, B., Burlingame, G. M., & Strauss, B. (2011). Der Gruppenfragebogen (GQ-D) [Group Questionnaire]. Psychotherapeut, 56, 297309. Burlingame, G. M., Strauss, B., & Joyce, A. S. (2014). Change mechanisms and effectiveness of small group treatment. In M. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 640-690). New York: Wiley. Davies-Osterkamp, S., Strauss, B., & Schmitz, N. (1996). Interpersonel problems as predictors of symptom related treatment in long-term psychotherapy. Psychotherapy Research, 6, 164-176. Eckert, J., & Biermann-Ratjen, E. M. (1985). Stationäre Gruppentherapie [Inpatient group psychotherapy]. Heidelberg, Germany: Springer. Grawe, K. (1980). Verhaltenstherapie in Gruppen [Behavioral therapy in groups]. Göttingen, Germany: Hogrefe. Hermanns, L. M. (2009). Über die Wurzeln der Gruppenanalyse im Nachkriegsdeutschland – Ihre Rezeptionsgeschichte und Traditionsbildung [The history of group analysis in postwar Germany – Its reception and specific traditions]. Gruppenpsychotherapie und Gruppendynamik, 45, 104-127. Hirsch, M. (2004). Gedanken zum Schwinden der Attraktivität analytischer Gruppentherapie [Thoughts about the reduced attractivness of analytic group psychotherapy]. Gruppenpsychotherapie und Gruppendynamik, 40, 164-178. Koenig, O. (2011). Vom allmählichen Verschwinden der Gruppentherapie [On the gradual disappearance of group therapy]. Psychotherapeut, 56, 287-296. Linden, M. (2014). Psychosomatic inpatient rehabilitation: The German model. Psychotherapy & Psychosomatics, 83, 205-212. Löffler, J., Bormann, B., Burlingame, G., & Strauss, B. (2007). Auswahl von Patienten für eine Gruppentherapie [Patient selection for group psychotherapy]. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 55(2), 75-86. Mattke, D., & Strauss, B. (2012). Aus-, Fort- und Weiterbildung in der Gruppentherapie [Training in group psychotherapy]. In B. Strauss & D. Mattke (Eds.), Gruppenpsychotherapie. Ein Lehrbuch für die Praxis [Group psychotherapy. A textbook for practitioners]. Berlin: Springer. Ogrodniczuk, J. S., Joyce, A. S., Lau, M. A., & Sochting, I. (2010). A survey of Canadian group psychotherapy association members’ perceptions of psychotherapy research. International Journal of Group Psychotherapy, 60, 159-176.
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Putnam, R. D. (1995). Bowling alone. America’s declining social capital. Journal of Democracy, 6, 65-78. Richter, H. E. (1972). Die Gruppe [The group]. Frankfurt, Germany: Rowohlt. Seidler, Ch. (2006). Die Gruppenpsychotherapie in der ehemaligen DDR [Group psychotherapy in the former German Democratic Republic]. In G. R. Gfäller & G. Leutz (Eds.), Gruppenanalyse, Gruppendynamik, Psychodrama [Group analysis, group dynamic, psychodrama] (pp. 164-183). Heidelberg, Germany: Mattes Verlag. Sipos, V., & Schweiger, U. (2013). Gruppentherapie. Ein Handbuch für die ambulante und stationäre verhaltenstherapeutische Praxis [Group therapy. Handbook of behavioral group therapy for inpatient and outpatient care]. Stuttgart, Germany: Kohlhammer. Staats, H., Dally, A., & Bolm, Th. (2014) Gruppenpsychotherapie und Gruppenanalyse [Group psychotherapy and group analysis]. Göttingen, Germany: Vandenhoeck & Ruprecht. Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41, 991-1007. Strauss, B., & Burgmeier-Lohse, M. (1994). Stationäre Langzeitgruppenpsychotherapie. [Long-term inpatient group psychotherapy]. Heidelberg, Germany: Asanger. Strauss, B., Burlingame, G. M., & Bormann, B. (2008). Using the CORE-R-Battery in group psychotherapy. Journal of Clinical Psychology, 64, 1225-1237. Strauss, B., Kirchmann, H., Eckert, J., Lobo-Drost, A., Marquet, A., Papenhausen, R., ... Höger, D. (2006). Attachment characteristics and treatment outcome following inpatient psychotherapy: Results of a multisite study. Psychotherapy Research, 16, 579-594. Strauss, B., Schreiber-Willnow, K., Kruse, J., Schattenburg, L., Seidler, K. P., Fischer, T., . . . Bormann, B. (2012). [Training background, everyday practice, and training needs of group therapists working in inpatient psychotherapy: Results of a survey]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(4), 394-408. Strauss, B., Spangenberg, L. Brähler, E., & Bormann, B. (2015). Attitudes toward (psychotherapy) groups. Results of a survey in a representative sample. International Journal of Group Psychotherapy, 65, 410-430. Tschuschke, V. (1993). Wirkfaktoren stationärer Gruppentherapie [Therapeutic factors of inpatient group psychotherapy]. Göttingen, Germany: Vandenhoeck & Ruprecht. Tschuschke, V., Anbeh, T., & Kiencke, P. (2007). Evaluation of long-term analytic outpatient group therapies. Group Analysis, 40(1), 140-159.
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von Rad, M., Senf, W., & Bräutigam, W. (1998). Psychotherapy and psychoanalysis in patient management: Results of the Heidelberg Catamnesis Project. Psychotherapy, Psychosomatics, Medical Psychology, 48(3-4), 88-100. Walendzcik, A., Rabe-Menssen, C., Lux, G., Wasem, J., Jahn, R, Dunker, C., & Farrenkopf, N. (2010). Erhebung zur ambulanten psychotherapeutischen Versorgung [Survey on on ambulatory psychotherapeutic care]. Universität Duisburg–Essen. Deutsche Psychotherapeuten Vereinigung DPTV. Weber, R., Ogrodnizcuk, J., Schultz-Venrath, U., & Strauss, B. (2012). Zum Verhältnis von Forschung und klinischer Praxis. Ergebnisse der Mitgliederbefragung der Deutschen Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G) zur Wahrnehmung von Psychotherapieforschung [The relation between research and clinical practice. A survey of Deutsche Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G) members’ perceptions of psychotherapy research]. Gruppenpsychotherapie und Gruppendynamik, 49, 37-52. Rainer Weber, Ph.D. Clinic for Psychosomatics and Psychotherapy University Hospital Cologne Kerpenerstrasse 68 D-50924 Cologne Germany E-mail: [email protected]
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Group Psychotherapy in Germany Rainer Weber Ph.D. & Bernhard Strauss Ph.D. To cite this article: Rainer Weber Ph.D. & Bernhard Strauss Ph.D. (2015) Group Psychotherapy in Germany, International Journal of Group Psychotherapy, 65:4, 513-525 To link to this article: http://dx.doi.org/10.1521/ijgp.2015.65.4.513
Published online: 19 Oct 2015.
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Article views: 5
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Date: 25 February 2016, At: 07:41
INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 65 (4) 2015 WEBER AND STRAUSS GROUP PSYCHOTHERAPY IN GERMANY
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Group Psychotherapy in Germany RAINER WEBER, PH.D. BERNHARD STRAUSS, PH.D.
ABSTRACT This article gives an overview of the development of group psychotherapies in Germany originating from a psychodynamic tradition. The German health system provides access to inpatient and outpatient psychotherapy for all of its citizens. Whereas groups are common in inpatient settings, the provision of outpatient group treatment still could be improved, as it is the case for the general training of group psychotherapists. Group research in Germany largely reflects clinical practice, with more studies coming from the inpatient field. It is stated that the general image of group treatment seems to be largely positive, which could provide a basis for political initiatives to improve the dissemination of group therapy in this country. HISTORICAL AND THEORETICAL BACKGROUND
T
here is no doubt that psychoanalytical theory in the tradition of Sigmund Freud and his successors dominated the development of both psychotherapy and group psychotherapy from the beginning of the 20th century. S. H. Foulkes (Siegismund Heinrich Fuchs), one of the founders of group analysis and the European group movement, studied medicine in Heidelberg, Munich, and Frankfurt. He completed his psychoanalytical training in Vienna. Rainer Weber is affiliated with the Clinic for Psychosomatics and Psychotherapy, University Hospital of Köln, Germany. Bernhard Strauss is affiliated with Jena University Hospital, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany.
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Later, in 1931 he acted as medical director of a psychiatric unit associated with the Frankfurt psychoanalytic institute. During his work in Frankfurt, he was strongly influenced by representatives of Gestalt psychology as well as the “Frankfurt School” of philosophy. In 1933, Foulkes emigrated to London following an invitation of Ernest Jones and became a lecturer and training analyst at the London Psychoanalytic Institute. In 1942, he started to work with groups after being posted to the Military Neurosis Centre at Northfield. After WWII, the small German psychoanalytic community struggled to regain recognition in the international psychoanalytic world. There are several reasons why group psychotherapy came (back) to Germany after the terror of the Nazi regime that caused a dramatic splitting of the local professional group of colleagues and isolation from the international community (Hermanns, 2009). In 1947, Foulkes presented his ideas on group therapy at an international conference on psychoanalysis (title of his talk: Group Psychotherapy and the Future of Our Culture) in Amsterdam. There was great debate about whether or not German psychoanalysts should be invited to this conference (Herrmanns, 2009). In August 1948, the 3rd International Conference on Mental Health took place in London with more than 2,500 participants from 50 different countries, including a small delegation from Germany. Group therapy was one of the major topics of the conference. Bion presented his work on groups. It is important to note that historically group therapy in Germany has primarily developed in inpatient settings (see below). Group therapy was selectively applied in some of the existing university hospitals (e.g., Tübingen, Freiburg, Giessen), initiated by medical directors who came in touch with practicing group therapists in the U.K. and the United States (Hermanns, 2009). Another important impulse for the development of group therapy in Germany came from the Lindauer Psychotherapiewochen (Lindau Psychotherapy Weeks), a conference founded in 1950 (and in its 65th year of existence with nearly 4,000 participating therapists every year) that provides continuing education for practitioners. In 1960, the major topic of the conference was psychotherapy in groups with Foulkes, Raoul Schindler, Walter
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Schindler, and Raymond Battegay as presenters and/or workshop leaders. As a consequence of these early initiatives, several group analytic training sites were developed under the auspices of the Institute of Group Analysis (IGA), for example, Altaussee (Austria), Heidelberg, and Münster. One of these initiatives was the group analysis seminars (GRAS) founded by Michael Lukas Moeller, who organized block trainings in group analysis by inviting several German-speaking British members of the IGA to serve as trainers and provide a Foulkesian form of group analysis. In 1960, Alexander Mitscherlich founded the Institute for Psychoanalysis and Pychosomatics, where group therapy played a significant role in the delivery of psychotherapeutic treatment. This institute, later renamed the Sigmund Freud Institute, favored Bion’s theory and the Tavistock tradition (Hermanns, 2009). Hermann Argelander was one of the leading individuals in Frankfurt, developing a specific approach to group analysis combining influences from Balint, Bion, and the Tavistock group. A third important tradition within the spectrum of psychodynamic group psychotherapy includes Annelise Heigl-Evers and her husband Franz Heigl as doyens of the development of group therapy in Germany. They founded Tiefenbrunn, a hospital for psychosomatic medicine and psychotherapy that became the cradle of the so-called Göttinger Modell (Göttinger model). This approach is associated with the theories of Foulkes, but also group dynamics, the philosophy of Hannah Arendt, and theme-centered interaction (TCI) developed by Ruth Cohn. One of its core features is the differentiation of the group approach according to the structural maturity level of the group members. Classical group analysis was for the most mature patients; more focused psychodynamic group was for patients with milder structural impairment, and psychodynamic-interactional group therapy was for patients with more severe mental problems and personality disorders (Staats, Dally, & Bolm, 2014). East Germany, an independent state between 1949 and 1990, was not only separated by the Berlin Wall erected in 1961, but also isolated from the dominant psychotherapeutic approaches of the time. Group therapy became the major treatment approach in the German Democratic Republic (GDR). Unlike in Western Europe, there was no unbroken psychoanalytical tradition. Psy-
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choanalysis was officially banned in the communist health care system. One of the leading psychotherapists in the GDR was Kurt Höck (1920–2008), a medical doctor and trained psychoanalyst. He formed the so-called Intendierte Dynamische Gruppentherapie (intended dynamic group psychotherapy) as a unique school of group psychotherapy that was strongly influenced by the theory of Kurt Lewin (Seidler, 2006). He also founded the hospital Berlin-Hirschgarten, which served as a model for group-oriented inpatient psychotherapy in the GDR. Another milestone in the development of group psychotherapy in Germany dates back to 1967: A group of therapists oriented toward psychoanalysis and group dynamics founded the Deutsche Arbeitskreis für Gruppenpsychotherapie und Gruppendynamik (DAGG; German Consortium of Group Psychotherapy and Group Dynamics). For many years, the DAGG was the professional association for psychoanalytic, group dynamically oriented, and psychodrama group psychotherapists in Germany. After intense internal conflict, the association dissolved in 2011. Members of the most influential section of the DAGG (the group analytic section) founded the Deutsche Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G; German Society for Group Analysis and Group Psychotherapy) in 2012. Within the DAGG, the psychodrama section was influential, representing an alternative group approach to group analysis. Since the 1970s, other group models spread through Germany. With a focus in Hamburg, client-centered group psychotherapy was cultivated by Reinhard and Annemarie Tausch, and largely influenced by Irving Yalom. Their attempt to publicly demonstrate group psychotherapy via television is still legendary. Between 1978 and 1980, they were responsible for a regular “life transmission” of client-centered groups (Psychotreff) on regional television. Parallel with the development of humanistic approaches, behavior therapists began to apply their treatment to group settings. One pioneer was Klaus Grawe (1945–2003), later a wellknown psychotherapy researcher, who, with Jochen Eckert and Nick Becker, chaired an inpatient unit providing parallel psychodynamic, humanistic, and behavioral group treatment for psychiatric patients at Hamburg University Hospital (Eckert & Bier-
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Table 1. Time Allocations for Group Therapy in Insurance-Covered Outpatient Care Psychodynamic
Psychoanalytic
CBT
Individual therapy (50 min. sessions)
Up to 80 [100]* sessions
Up to 240 [300]* sessions
Up to 60 [80] sessions
Group therapy with adults (100 min. sessions)
40–60 [80]* sessions
60–120 [150] sessions
Up to 80 sessions (individual and/or group sessions of 50 min. duration)
Children/adolescents
40–60 sessions (100 min.)
40–60 sessions (100 min.)
45–60 sessions (individual and/or group sessions of 50 min. duration)
*Absolute maximum, has to be justified.
mann-Ratjen, 1985). In 1980, Grawe edited the first textbook, Behavior Therapy in Groups (Grawe, 1980), establishing another important group tradition in the German health care system that has become increasingly important. THE ROLE OF GROUP THERAPY IN THE GERMAN HEALTH CARE SYSTEM
Statutory health insurance is a major pillar of the German health care system, meaning that almost every citizen (approximately 90%) is insured against costs of illness; approximately 10% use private health insurance. Psychotherapy has been covered by the health insurance system since 1967. Outpatient psychotherapy is regulated by a continuously revised law, the Psychotherapierichtlinien (psychotherapy rules), which includes psychoanalytic, psychodynamic, and cognitive behavioral therapy; they are all now thought to have demonstrated their scientific effectiveness. Other psychotherapeutic approaches are currently not covered by insurance. Group therapy allocations within outpatient treatment are summarized in Table 1. For each patient in individual and group therapy, psychotherapists are required to write a report that is anonymously evaluated by an independent reviewer. This procedure is thought to ensure quality by establishing the medical necessity for treatment, the treatment plan, and the allocation of insurance money. In 2010, the German Association of Psychotherapists (Deutsche Psychotherapeutenvereinigung; DPTV) organized a survey among German therapists working in private practice
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(Walendzik et al., 2011). It revealed that 24.2% of all therapists possessed a license to work with groups (for training guidelines in group therapy, see below), but only about one-third currently provide groups in their therapeutic work. Asked about reasons for this discrepancy, the therapists primarily reported administrative issues, for example, writing case reports for each patient and difficulties in establishing a group. Interestingly, therapists in rural areas were more actively running groups, probably due to the pressures of supply and demand. One specific feature of the German health care system is the prevalence of a large number of hospital beds for patients needing inpatient psychotherapy and psychosomatic care. In 2004, German hospitals covered 122 special units for psychosomatic medicine and psychotherapy, with more than 4,412 inpatient beds (Barghaan, Schulz, Koch, & Watzke, 2009). In addition, hospitals specialized for psychosomatic inpatient rehabilitation cover almost 25,000 beds (Linden, 2014). In most of these hospitals, group therapy is the treatment of choice, usually as an adjunct to other treatment approaches, such as art therapy, creative and body-oriented treatments, occupational therapy, and so forth. TRAINING IN GROUP THERAPY
In the German health care system, psychotherapists need specific qualifications to obtain the license for billing group treatment to insurance companies (Mattke & Strauss, 2012). Currently, in order to work with groups in private practice, professionals are required to have training in individual therapy, either as a psychologist or as a medical doctor, plus the following additional requirements related to their primary therapeutic orientation (i.e., psychodynamic, psychoanalytic, or cognitive-behavioral): • 40 sessions (90–100 min.) personal therapy in a group • 48 hours theoretical training (group theory and group dynamics) • 60 hours group therapy under supervision (with a minimum of 40 sessions supervision)
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Membership in a group psychotherapeutic society (optional) requires more advanced training, including more hours of theory and personal therapy as well as group psychotherapeutic practice The situation for those practicing group therapy within hospitals is completely different. There, it is more often the rule that groups are directed by psychologists or medical doctors with no experience or specific training or education in group therapy (Strauss et al., 2012). Accordingly, a number of initiatives are in place directed towards providing time-limited and focused training for therapists working in institutions with psychotherapeutic inpatient and/or day treatment (e.g., Mattke & Strauss, 2012). GROUP THERAPY AND RESEARCH IN GERMANY
Bridging the gap between group psychotherapy research and practice is a constant challenge. In order to achieve a meaningful synthesis of research and practice, scientists must focus on issues that practitioners identify as important and useful. Ogrodnizcuk, Joyce, Lau, and Sochting (2010) published a survey of Canadian Group Psychotherapy Association members’ perceptions of psychotherapy research. The objective of the survey was to identify research topics and issues important to group psychotherapists. Due to the uniqueness of the German service delivery model, Weber, Ogrodnizcuk, Schultz-Venrath, and Strauss (2012) carried out a parallel study in Germany among members of the Germany Society for Group Analysis and Group Psychotherapy (D3G). Surprisingly, there were no significant differences between the German and Canadian samples regarding the main topics; similar limitations of current research were reported. Many respondents thought that research would distort or even interrupt the therapeutic process. They indicated a lack of qualitative and single case-study research designs and an overemphasis on randomized controlled trial (RCT) studies. A large proportion of both samples believed that researchers should focus on the study of relationship variables instead of specific treatment techniques, and that research results should be communicated in a more “digestible” way. When asked about research areas that would be
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important in the future, understanding group processes, group leaders’ behavior, and cost-effectiveness issues were commonly mentioned. During the past decades, there has been some group psychotherapy research. However, RCT studies were primarily limited to CBT (e.g., Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003). Within the outpatient field, the so-called PAGE-Studie (Tschuschke, Anbeh, & Kiencke, 2007) provides the only huge naturalistic group therapy study in Germany. The authors conducted a process-outcome study with three forms of group treatment: psychoanalytic, psychodynamic, and psychodrama. Primarily, the authors were interested in describing changes in psychological symptoms, interpersonal problems, therapy goals, and global assessment of functioning. The sample consisted of 40 therapists who had treated more than 600 patients. The results of the study underline the general effectiveness of outpatient group therapy without supporting interpretations of the efficacy of specific treatments. Consistent with the dominance of inpatient group treatments in Germany, studies in effectiveness and process research in inpatient settings prevailed. Some studies tried to reflect the complexity of inpatient group work, for example, the Hamburg study of inpatient group therapy (Eckert & Biermann-Ratjen, 1985), the Heidelberg Follow-up Project (von Rad, Senf, & Bräutigam, 1998), the Stuttgart Group Therapy Study (Tschuschke, 1993), and the Kiel Group Therapy Study (Strauss & Burgmeier-Lohse, 1994). Bernhard Strauss and Jochen Eckert founded a research network for inpatient group research in 1989 with members from university as well as general and rehabilitation hospitals. Within this network, several studies addressed the question of whether interpersonal problems and/or attachment characteristics serve as predictors for treatment outcome and therapeutic factors in inpatient group treatment (e.g., Davies-Osterkamp, Strauss, & Schmitz, 1996; Strauss et al., 2006). Some German researchers have always had close working relationships with their North American colleagues (e.g., Volker Tschuschke with Robert Dies and K. Roy MacKenzie). During the past two decades, the research group in Jena had a fruitful collab-
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oration with Gary Burlingame and his group at Brigham Young University (BYU), resulting in comprehensive reviews of the research literature (e.g., Burlingame, Strauss, & Joyce, 2014) and in the collection (AGPA Core Battery; Strauss, Burlingame, & Bormann, 2008) and adaptation of measures for group research, for example, the Group Readiness Scale and the Group Questionnaire (Bormann, Burlingame, & Strauss, 2011; Löffler, Bormann, Burlingame, & Strauss, 2007). In addition to a large number of texts related to group psychotherapy and group dynamics, the journal Gruppenpsychotherapie und Gruppendynamik has been important as a vehicle for theoretical and research articles on group issues for more than 50 years. The research literature comprises conceptual work, such as the development and application of specific treatment models and studies validating research measures as well as process and outcome studies such as those mentioned above. UNIQUE ISSUES RELATED TO GROUP THERAPY IN GERMANY
The anchoring of psychotherapy as a standard insurance benefit in the health care system and the huge number of hospitals providing group psychotherapy are probably unique features of group treatment in Germany. While the psychodynamic tradition had an enormous influence on psychotherapy in Germany, humanistic and, increasingly, CBT–related approaches are also important sources of group training and research (e.g., Sipos & Schweiger, 2013). THE FUTURE OF GROUP WORK IN GERMANY
The development of group psychotherapy in Germany is strongly connected to the role of psychoanalysis in Europe before, during, and after World War II. As in many other Western countries, group methods experienced a surge of interest following the student protests of the late 1960s. Horst Eberhard Richter (1972) published a popular book on how groups might assist in the proliferation of high social and moral expectations of others and the hope that a group culture could contribute to societal change and assist in overcoming the Nazi period. During the 1970s and
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1980s, groups were popular in many fields inside and outside the health care system. Recently, several authors from sociology and/or psychoanalysis (e.g., Hirsch, 2004; Koenig, 2011) argued that groups have lost their attractiveness and importance over the past two or three decades, reflecting diminished expectations, an increased tendency to withdraw from social interaction, and a decline of “social capital” (Putnam, 1995). A more recent study addressed people’s group-related attitudes and experiences (Strauss, Spangenberg, Brähler, & Bormann, 2015). It revealed a surprisingly positive picture of attitudes towards and expectations with groups in general, and psychotherapy groups in particular. At least 6% of a representative sample of more than 2,500 individuals revealed experiences with group psychotherapy, underscoring the status of groups within the health care system. Yet, from a health care service perspective, there is still a discrepancy between the (low) number of psychotherapists offering group treatment and the waiting time until individuals begin outpatient psychotherapy. Accordingly, the current government of Germany, consisting of a coalition of three political parties, has decided to include a position in their coalition agreement stating that psychotherapeutic outpatient service must be improved, and that “the provision of group psychotherapy should be supported.” This is the first time that health care politics have actively promoted group psychotherapy. The coalition declaration may be accompanied by specific actions, such as omission of the required case reports and an increase in the honorarium paid to clinicians providing group intervention. If successful, these actions could well form the basis for improving access to group treatment in Germany and other countries.
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therapeutic orientations]. Gruppenpsychotherapie und Gruppendynamik, 48, 83-103. Bormann, B., Burlingame, G. M., & Strauss, B. (2011). Der Gruppenfragebogen (GQ-D) [Group Questionnaire]. Psychotherapeut, 56, 297309. Burlingame, G. M., Strauss, B., & Joyce, A. S. (2014). Change mechanisms and effectiveness of small group treatment. In M. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 640-690). New York: Wiley. Davies-Osterkamp, S., Strauss, B., & Schmitz, N. (1996). Interpersonel problems as predictors of symptom related treatment in long-term psychotherapy. Psychotherapy Research, 6, 164-176. Eckert, J., & Biermann-Ratjen, E. M. (1985). Stationäre Gruppentherapie [Inpatient group psychotherapy]. Heidelberg, Germany: Springer. Grawe, K. (1980). Verhaltenstherapie in Gruppen [Behavioral therapy in groups]. Göttingen, Germany: Hogrefe. Hermanns, L. M. (2009). Über die Wurzeln der Gruppenanalyse im Nachkriegsdeutschland – Ihre Rezeptionsgeschichte und Traditionsbildung [The history of group analysis in postwar Germany – Its reception and specific traditions]. Gruppenpsychotherapie und Gruppendynamik, 45, 104-127. Hirsch, M. (2004). Gedanken zum Schwinden der Attraktivität analytischer Gruppentherapie [Thoughts about the reduced attractivness of analytic group psychotherapy]. Gruppenpsychotherapie und Gruppendynamik, 40, 164-178. Koenig, O. (2011). Vom allmählichen Verschwinden der Gruppentherapie [On the gradual disappearance of group therapy]. Psychotherapeut, 56, 287-296. Linden, M. (2014). Psychosomatic inpatient rehabilitation: The German model. Psychotherapy & Psychosomatics, 83, 205-212. Löffler, J., Bormann, B., Burlingame, G., & Strauss, B. (2007). Auswahl von Patienten für eine Gruppentherapie [Patient selection for group psychotherapy]. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 55(2), 75-86. Mattke, D., & Strauss, B. (2012). Aus-, Fort- und Weiterbildung in der Gruppentherapie [Training in group psychotherapy]. In B. Strauss & D. Mattke (Eds.), Gruppenpsychotherapie. Ein Lehrbuch für die Praxis [Group psychotherapy. A textbook for practitioners]. Berlin: Springer. Ogrodniczuk, J. S., Joyce, A. S., Lau, M. A., & Sochting, I. (2010). A survey of Canadian group psychotherapy association members’ perceptions of psychotherapy research. International Journal of Group Psychotherapy, 60, 159-176.
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Putnam, R. D. (1995). Bowling alone. America’s declining social capital. Journal of Democracy, 6, 65-78. Richter, H. E. (1972). Die Gruppe [The group]. Frankfurt, Germany: Rowohlt. Seidler, Ch. (2006). Die Gruppenpsychotherapie in der ehemaligen DDR [Group psychotherapy in the former German Democratic Republic]. In G. R. Gfäller & G. Leutz (Eds.), Gruppenanalyse, Gruppendynamik, Psychodrama [Group analysis, group dynamic, psychodrama] (pp. 164-183). Heidelberg, Germany: Mattes Verlag. Sipos, V., & Schweiger, U. (2013). Gruppentherapie. Ein Handbuch für die ambulante und stationäre verhaltenstherapeutische Praxis [Group therapy. Handbook of behavioral group therapy for inpatient and outpatient care]. Stuttgart, Germany: Kohlhammer. Staats, H., Dally, A., & Bolm, Th. (2014) Gruppenpsychotherapie und Gruppenanalyse [Group psychotherapy and group analysis]. Göttingen, Germany: Vandenhoeck & Ruprecht. Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41, 991-1007. Strauss, B., & Burgmeier-Lohse, M. (1994). Stationäre Langzeitgruppenpsychotherapie. [Long-term inpatient group psychotherapy]. Heidelberg, Germany: Asanger. Strauss, B., Burlingame, G. M., & Bormann, B. (2008). Using the CORE-R-Battery in group psychotherapy. Journal of Clinical Psychology, 64, 1225-1237. Strauss, B., Kirchmann, H., Eckert, J., Lobo-Drost, A., Marquet, A., Papenhausen, R., ... Höger, D. (2006). Attachment characteristics and treatment outcome following inpatient psychotherapy: Results of a multisite study. Psychotherapy Research, 16, 579-594. Strauss, B., Schreiber-Willnow, K., Kruse, J., Schattenburg, L., Seidler, K. P., Fischer, T., . . . Bormann, B. (2012). [Training background, everyday practice, and training needs of group therapists working in inpatient psychotherapy: Results of a survey]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(4), 394-408. Strauss, B., Spangenberg, L. Brähler, E., & Bormann, B. (2015). Attitudes toward (psychotherapy) groups. Results of a survey in a representative sample. International Journal of Group Psychotherapy, 65, 410-430. Tschuschke, V. (1993). Wirkfaktoren stationärer Gruppentherapie [Therapeutic factors of inpatient group psychotherapy]. Göttingen, Germany: Vandenhoeck & Ruprecht. Tschuschke, V., Anbeh, T., & Kiencke, P. (2007). Evaluation of long-term analytic outpatient group therapies. Group Analysis, 40(1), 140-159.
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von Rad, M., Senf, W., & Bräutigam, W. (1998). Psychotherapy and psychoanalysis in patient management: Results of the Heidelberg Catamnesis Project. Psychotherapy, Psychosomatics, Medical Psychology, 48(3-4), 88-100. Walendzcik, A., Rabe-Menssen, C., Lux, G., Wasem, J., Jahn, R, Dunker, C., & Farrenkopf, N. (2010). Erhebung zur ambulanten psychotherapeutischen Versorgung [Survey on on ambulatory psychotherapeutic care]. Universität Duisburg–Essen. Deutsche Psychotherapeuten Vereinigung DPTV. Weber, R., Ogrodnizcuk, J., Schultz-Venrath, U., & Strauss, B. (2012). Zum Verhältnis von Forschung und klinischer Praxis. Ergebnisse der Mitgliederbefragung der Deutschen Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G) zur Wahrnehmung von Psychotherapieforschung [The relation between research and clinical practice. A survey of Deutsche Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G) members’ perceptions of psychotherapy research]. Gruppenpsychotherapie und Gruppendynamik, 49, 37-52. Rainer Weber, Ph.D. Clinic for Psychosomatics and Psychotherapy University Hospital Cologne Kerpenerstrasse 68 D-50924 Cologne Germany E-mail: [email protected]
