Special Article Psychother Psychosom 2014;83:205–212 DOI: 10.1159/000358852
Received: September 12, 2013 Accepted after revision: January 18, 2014 Published online: June 19, 2014
Psychosomatic Inpatient Rehabilitation: The German Model Michael Linden Department of Psychosomatic Medicine, Rehabilitation Center Seehof, Federal German Pension Agency, and Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Teltow/Berlin, Germany
Key Words Psychosomatic medicine · Disability · Rehabilitation · Inpatient treatment · Burnout · Chronic mental illness
Abstract The term ‘psychosomatic’ has many connotations, be it in the sense of a general biopsychosocial concept in medicine as outlined in the ICF (International Classification of Functioning, Disability and Health) of the World Health Organization, a holistic and person-centered view of the patient beyond the illness, the treatment of somatoform or somatic disorders, or special psychotherapeutic approaches. In Germany, there are also about 25,000 inpatient beds in ‘psychosomatic rehabilitation hospitals’, which treat approximately 5/1,000 inhabitants in the working age population per year. These institutions give an example of how to translate the theoretical concepts of psychosomatic medicine and of the ICF into clinical practice. ‘Psychosomatic rehabilitation’ aims at the prevention, treatment and compensation of chronic illness by a biopsychosocial approach. This includes a multilevel psychosomatic assessment and a multidimensional treatment focus including the reduction of symptoms, the training of capacities, the coping with chronic illness and impairment, the restoration of well-being and normal life, and the occupational reintegration including the search for a workplace, which allows work in spite of impairment. Scien-
© 2014 S. Karger AG, Basel 0033–3190/14/0834–0205$39.50/0 E-Mail [email protected] www.karger.com/pps
tific studies have shown that the psychological status, the motivation to work, the number of days on sickness leave and occupational reintegration can be improved, and that the system pays for the patients themselves, but also pension and health insurance companies. © 2014 S. Karger AG, Basel
Psychosomatic Medicine
The term ‘psychosomatic’ has many connotations. Psychosomatic medicine is first of all a theoretical concept as described by Meyer [1, 2], von Weizsäcker [3], Engel [4, 5] or Fava and associates [6–9], which is synonymous to the biopsychosocial concept in medicine, and which is also underlying the ICF (International Classification of Functioning, Disability and Health) of the World Health Organization [10]. Some scientists use it to describe what every physician should do when dealing with a patient, i.e. not look at the illness only but at the patient as a suffering individual [11]. For others it is the treatment of somatic illnesses by psychological methods and interventions [12]. Some understand psychosomatic medicine as the treatment of somatoform disorders, i.e. mental illnesses which express themselves by unexplained somatic symptoms [13]. It is also used synonymously for patient education and helping patients to cope with their Prof. Dr. Michael Linden Rehabilitation Center Seehof Lichterfelder Allee 55 DE–14513 Teltow/Berlin (Germany) E-Mail michael.linden @ charite.de
illness, be it in the individual physician-patient encounter or in structured educational groups [14]. Another definition is found in ‘basic psychosomatic care’ which is a type of limited psychotherapy and which can only be applied after a special training and licensing in some countries like Germany [15]. Psychosomatic medicine is also used synonymously with structured psychotherapy [15]. There are also medical specialties like ‘specialists for psychosomatic medicine and psychotherapy’ with a 5-year training and official licensing [16]. Finally, there are ‘psychosomatic inpatient facilities’ in acute and in rehabilitation hospitals [17]. Based on the theoretical framework of biopsychosocial medicine and the corresponding definitions of ‘psychosomatic medicine’ [6–8], this paper will give an example of how this concept can be translated into practical patient care. This will be done with reference to psychosomatic medicine as practiced in ‘psychosomatic rehabilitation hospitals’ in Germany.
The Psychosomatic Rehabilitation System in Germany
As psychosomatic inpatient rehabilitation units are a German peculiarity, it is first necessary to describe this type of health care system. This also includes an explanation of the meaning of rehabilitation, which is a biopsychosocial approach in itself and therefore has also a direct significance for the practice of psychosomatic medicine. According to the German Social Law (SGB IX), all negative health states which last longer than 6 months and which are associated with present or impending restrictions in social or occupational participation are called disability and are subject of rehabilitation. In addition to vocational rehabilitation and other forms of social support, there is also ‘medical rehabilitation’ which, according to the law, aims at the primary prevention, treatment, compensation and secondary prevention of chronic illness and which has to use all available medical means like treatment by physicians, psychotherapy, medication etc. In the first place, this type of care is reimbursed by health insurance or state social security. If early retirement is pending, the pension insurance agency steps in to prevent ill-health retirement. The first inpatient ‘psychosomatic’ hospital in Germany was founded in 1929 by V. von Weizsäcker und L. Krehl in Heidelberg. The first psychosomatic rehabilitation hospitals started with a psychodynamic orientation in the sixties, and behavior therapy units followed in the 206
Psychother Psychosom 2014;83:205–212 DOI: 10.1159/000358852
Table 1. Characteristics of the therapeutic milieu in inpatient psychosomatic rehabilitation
Improved diagnosis Intensive treatment Shelter Relief of demands and burdens Structuring of the day Therapeutic demands Practice field Motivation Model learning Contact with others Reliable observation for expert assessment of the illness state, prognosis and ability to work
seventies. Today there are about 25,000 beds in inpatient rehabilitation units in Germany or 0.3/1,000 persons of the general population. These psychosomatic rehabilitation units take care of about 200,000 patients/year, i.e. 2.5/1,000 of the general population or about 5/1,000 of those in the working age group. Patients themselves or their treating physicians can apply for inpatient rehabilitation. A major part of patients is sent to inpatient treatment by the health insurance company after being on sick leave for few weeks or by the pension insurance company when they apply for early retirement [18]. Because of this way of referral, patients are suffering from all types of mental illness. There are also patients who would never have asked for treatment if they had not been sent in by an insurance company and who may therefore suffer from so far undiagnosed problems. Before admission the treating physicians have to write a case report which is reviewed by physicians of the insurance company, who have to approve the admission and also select the hospital. The length of stay , in most cases 5 weeks, is set from the beginning by health and pension insurance agencies before admission of the patient, and can only be shortened or prolonged in special cases. Patients are sent to hospitals throughout the country, because all units have specialties which are known to the insurance companies. There are rehabilitation hospitals which are specialized in addiction, eating disorders, schizophrenia, borderline disorder or pain. Most will also treat depression, anxiety disorders or somatoform disorders. These patients with chronic mental disorders are sent to inpatient units because of the advantages of treatment in a ‘therapeutic milieu’ (table 1). This includes distance Linden
ICD
ICF
Therapy
Complaint, symptom
Disorder of function
Treatment of symptoms
Diagnostic algorithm
Limitation of capacity
Training of capacities
ICD-10 diagnosis
Context
Change of context
Sickness status Restriction of participation
Social support (e.g. pension) Salutotherapy
Treatment permission
Fig. 1. ICD, ICF and psychosomatic treat-
ment goals.
from daily burdens, structuring of the day, model learning, or intensive and comprehensive treatments [19]. It is also of importance that at the end of the stay the insurance company expects a medical report on the ability to work or the degree of impairment [20–22]. Inpatient treatment allows more thorough evaluations than short-term ambulatory assessments.
Treatment Goals of Psychosomatic Rehabilitation according to the ICF
The underlying theoretical guideline of inpatient psychosomatic rehabilitation is the biopsychosocial model of the ICF [10, 23]. This includes diagnoses according to the ICD-10. However, these diagnoses alone cannot tell how to treat a patient. Treatment is targeting and guided, in the terminology of the ICF, by ‘disorders of functions’, i.e. symptoms, ‘limitations in capacity’ and ‘restrictions of participation’. Finally, ‘restrictions of participation’ occur when the personal or environmental context and individual capacities are not in accordance. Figure 1 gives an overview on the relation between ICD and ICF. Complaints are translated by diagnostic algorithms into diagnoses, which are a prerequisite for treatment. Medication without a diagnosis is doping, whereas with a diagnosis it is therapy. Complaints of patients, in contrast to complaints of healthy persons, are Psychosomatic Inpatient Rehabilitation
‘symptoms’ or ‘disorders of function’ according to ICD [24] and ICF [10]. The goals of treatment can be structured and classified according to the biopsychosocial model of the ICF. The first goal of any treatment is to reduce symptoms or restore functions, like concentration, emotional state, formal thinking, or drive. If this cannot be achieved, the second goal is to improve capacities. Examples are assertiveness or social competency. If then there is still an insufficient coping with daily life, e.g. inability to work, the third goal is to modify the context, i.e. work demands, so that the impaired person can still participate in daily life. Finally, if nothing more can be done, there are still the goals of protecting or improving quality of life and well-being and of providing social security, e.g. by granting a pension or sheltered living. In summary, treatment goals take into account the present type and severity of illness, but go far beyond and focus also on psychological and social aspects, i.e. take a holistic view on the patient and his living situation. This broadened view is of less relevance in acute illness episodes but indispensable in chronic illnesses where their impact on well-being, coping with daily demands and living conditions often has more negative consequences for the patient than the symptoms of illness as such. Rehabilitation medicine is therefore inevitably biopsychosocial or psychosomatic in the general sense of the word.
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Diagnosis and treatment of illness
Diagnostic reassessment
Curative and/or palliative treatment
Prophylaxis
Training of capacities
Coping with illness
Long-term medical care
Treatment compliance
Disability benefits
Coping with disability
Chronic illness, quality of life, participation
Occupational participation
Self-concept
Lifestyle
Assessment of disability
Work reintegration, social assessment
Social net
Activities of daily living
Well-being
Salutotherapy, compensation of illness
Fig. 2. Therapeutic interventions in psychosomatic inpatient rehabilitation.
Inpatient Psychosomatic Treatment Process
These multiple treatment goals have to be translated into a multidimensional and multidisciplinary treatment process. As the average duration of the inpatient stay is about 5 weeks, treatment has to be planned so that adequate results can be achieved in this short period of time. Figure 2 gives an overview of what is done under a psychosomatic perspective. The first task in inpatient psychosomatic rehabilitation is to review the diagnosis according to ICD/DSM algorithms [24, 25] but also to a more comprehensive psychosomatic perspective [9, 26, 27]. Most prevalent are mood disorders, anxiety disorders, adjustment disorders, somatoform disorders and personality disorders, which is similar to the spectrum of mental disorders in the general population or in primary health care [28] and different from psychiatric acute care hospitals. Such chronic psychological disorders are often diagnostically ambiguous and multidimensional, e.g. a patient may complain about depressed mood and look as if he were suffering from a depressive illness while in fact the problem is sleep apnea, alcohol abuse or just unhappiness [29]. 208
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Because of the specialties of admittance there are furthermore types of disorders which will not be seen in other psychiatric institutions or are not described or covered in ICD [24] or DSM [25]. Examples are embitterment reactions, work phobia, resilience deficit syndromes, mild cognitive dysfunctions, demoralization or irritable mood [9, 30–38]. Assessment also includes a functional analysis of interactions between mental disorder, personality and environment [39]. In some cases, new diagnostic insights, including a broadened view on life events and psychosocial factors, open the way to new and effective treatments. The question to be answered is whether the present negative health status is chronic or only pseudochronic. Chronicity is defined as persistence of symptoms in spite of intensive treatment efforts [40, 41]. Because of the specialization of rehabilitation units there are, for example, some with dozens of anorexia patients at a time, which allows interventions beyond what is possible in regular outpatient care [17, 27]. Treatment includes medication and other somatic treatments and most of all psychotherapy. Psychosomatic rehabilitation hospitals all have a high psychotherapeutic expertise, be it psychodynamic or cogniLinden
tive-behavioral. Patients regularly get single and group psychotherapy. They are additionally treated by sport therapists, occupational therapists and social workers. This allows complex treatment regimens. A patient with hypochondriacal cardiac problems will be seen by a physician and get a medical workup; he will then be treated in single and group psychotherapy to learn anxiety management. He will get exposure treatment in sport therapy. In occupational therapy he will learn to distract himself from anxiety and engage in compensatory activities and enjoy life, and will get support by social workers on how to find his way back to work. Treatment also includes prophylaxis of recurrent episodes or illness deterioration. This can be prophylactic medication and/or prophylactic psychotherapy. Many psychotherapies like ‘well-being therapy’ [42, 43] have been shown to have prophylactic effects even in primarily treatment-resistant cases. In addition to the treatment of symptoms or disorders of function, another level of interventions aims at improving capacities or coping ability. There are well-established and evidence-based treatments to improve such capacities. Examples are problem-solving capacities [44], assertiveness and social competency [45], time management [46], stress management [47], flexibility [48] or work hardiness [49]. Such capacities can help to ameliorate retroactively symptoms but, more importantly, they decide about secondary consequences of illness and social or occupational participation. If the illness cannot be cured, the next important treatment goal is to help the patient cope with the illness and chronic impairment and improve ‘illness behavior’ [50, 51]. Patients have to adapt health attitudes, accept and support treatment and learn to adjust their lives to the chronic illness. Apart from general patient education and improvement of patient compliance, an important general treatment concept is the SOC (selection-optimization-compensation) paradigm from Baltes [52]. It encompasses ‘selection’ of what can still be done in spite of the chronic state of illness. This should be ‘optimized’ by training and it should be ‘compensated’ what can no longer be done. Patients with personality disorders, for example, are invited to look in detail for their strengths and then make the best out of it, while trying to compensate what leads to misunderstandings [38]. A third area of interventions aims at the improvement of quality of life [53]. Most chronic illnesses impair the subjective well-being, contentment with life, daily activities, leisure activities or social contacts. There are patients who have not been to a cinema for years, because they did Psychosomatic Inpatient Rehabilitation
Table 2. Therapeutic interventions to support work reintegration
Individual psychotherapy to improve self-efficacy, reduction in anxiety, etc. Competency training by occupational therapists (concentration, endurance, functional training) Special group therapies: conflict management at the workplace, work hardening, etc. Internet search for new job opportunities Application for jobs with the support of therapists Counseling for occupational rehabilitation Individual counseling for work-related problems Contacts with the employer Training at workplaces during inpatient stay Group psychotherapy after the inpatient stay for up to a year Follow-up counseling
not feel like it. To safeguard or improve healthy areas of life or quality of life is often more important than to change symptoms of illness. There is a broad spectrum of evidence-based interventions which can be summarized under the heading of ‘salutotherapy’ [54–56]. Examples are to support self-care, or increase daily, cultural or creative activities. Most important is it to safeguard the social net and foster social encounters [57, 58]. Another important area of treatment interventions aims at helping patients to cope with work demands or find their way back to work [59–64]. During recent years pension insurance has stimulated rehabilitation centers to put more emphasis on this part of treatment (table 2). This starts with looking at illnesses from a participation perspective instead of from a pure symptom orientation. An example is anxiety in relation to the job, i.e. workrelated anxiety and workplace phobia [35, 36], which can be differentiated from anxiety in general. Workplace phobia is a disorder which is especially suited to explain the biopsychosocial approach in psychosomatic medicine: any workplace is full of possible anxiety-provoking features like superiors with their demands and evaluations, colleagues and rivalries, aggressive customers, health threats or job insecurity. Workplace-related anxiety or even workplace phobia need special attention and psychotherapeutic strategies. First of all there are pharmacological and psychotherapeutic ways to ameliorate the level of general anxiety. Exposure treatment can be supported by practical training in some real-life workplaces, where patients are sent to during their inpatient stay. Patients can go back to their own workplace after discharge from hospital in a graded manner, starting with few hours per day and then increasing their presence at Psychother Psychosom 2014;83:205–212 DOI: 10.1159/000358852
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work in a stepwise manner. If there are conflicts at work, therapists can contact the parties involved and try to solve the problem. If patients can no longer fulfill regular work demands, the employers are contacted in search for a workplace suitable for the patient. Patients with social anxiety can be transferred to an office instead of working with clients. Some patients need support in finding new work, be it by applications for employment or by finding new occupational perspectives. They can be transferred to occupational training. There is also the opportunity to participate in group treatment for about a year after discharge from hospital, which is paid by the pension insurance and aims at improving work participation. If the ability to work cannot be reinstalled, social support has to be found and initiated. This can be sickness compensation or pension or welfare benefits. Finally, all patients have to be guided to find adequate long-term treatment and care after discharge from hospital [27]. This can be self-help groups, contact to counseling institutions, treatment and guidance by general practitioners or ambulatory specialists, specialized ambulatory psychotherapy or disease management programs.
Quality Assurance, Effectiveness and the International Perspective
The system is subject to close monitoring and quality assurance by the pension agency. All therapeutic interventions are coded according to a classification scheme for therapeutic interventions [65] and reported to the pension insurance company, which controls the duration of inpatient stays. They overview the number and qualification of the personnel, they make regular visits and talk to patients and therapists, they undertake standardized peer review assessments of physician’s letters and medical reports, they collect and report the number of patient complaints, and send a feedback questionnaire to a sam-
ple of patients weeks after dismissal. Finally, the pension insurance company has all data on the working status of patients in the years before and after medical rehabilitation. The primary outcome of inpatient rehabilitation is a valid expert judgements on whether patients are able or unable to work and deserve ill-health retirement or not. Additionally it is also of interest whether the health status of patients can still be improved. There are several studies on positive effects with respect to improvement of the medical and psychological status of patients, their social impairment, the motivation to work, the number of days on sickness absence, reduction of early retirement and occupational reintegration [59, 60, 66–80]. An important outcome parameter is that the system saves money for the pension insurance. The costs for inpatient rehabilitation are about EUR 130 per day, i.e. about EUR 4,000–5,000 in total. The pension insurance agency has a direct financial benefit when patients stay at work for only 3 additional months. A proof for the effectiveness of psychosomatic rehabilitation is that the pension insurance agency, which has all pertinent data, has continuously implemented more and more rehabilitation facilities over the years [20, 76–79]. This system of inpatient psychosomatic rehabilitation is unique in the world although some other countries have started similar projects in recent years like Poland or Austria, where the number of respective facilities has also grown up to 100% during the last few years. The psychosomatic rehabilitation hospitals make an important contribution to the health care of patients with chronic mental disorders, supplementary to acute inpatient care and ambulatory care. Rehabilitation hospitals allow a unique access to special patient groups and medical problems which are not seen in other health care facilities, which provides opportunities for research or medical education.
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Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Received: September 12, 2013 Accepted after revision: January 18, 2014 Published online: June 19, 2014
Psychosomatic Inpatient Rehabilitation: The German Model Michael Linden Department of Psychosomatic Medicine, Rehabilitation Center Seehof, Federal German Pension Agency, and Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Teltow/Berlin, Germany
Key Words Psychosomatic medicine · Disability · Rehabilitation · Inpatient treatment · Burnout · Chronic mental illness
Abstract The term ‘psychosomatic’ has many connotations, be it in the sense of a general biopsychosocial concept in medicine as outlined in the ICF (International Classification of Functioning, Disability and Health) of the World Health Organization, a holistic and person-centered view of the patient beyond the illness, the treatment of somatoform or somatic disorders, or special psychotherapeutic approaches. In Germany, there are also about 25,000 inpatient beds in ‘psychosomatic rehabilitation hospitals’, which treat approximately 5/1,000 inhabitants in the working age population per year. These institutions give an example of how to translate the theoretical concepts of psychosomatic medicine and of the ICF into clinical practice. ‘Psychosomatic rehabilitation’ aims at the prevention, treatment and compensation of chronic illness by a biopsychosocial approach. This includes a multilevel psychosomatic assessment and a multidimensional treatment focus including the reduction of symptoms, the training of capacities, the coping with chronic illness and impairment, the restoration of well-being and normal life, and the occupational reintegration including the search for a workplace, which allows work in spite of impairment. Scien-
© 2014 S. Karger AG, Basel 0033–3190/14/0834–0205$39.50/0 E-Mail [email protected] www.karger.com/pps
tific studies have shown that the psychological status, the motivation to work, the number of days on sickness leave and occupational reintegration can be improved, and that the system pays for the patients themselves, but also pension and health insurance companies. © 2014 S. Karger AG, Basel
Psychosomatic Medicine
The term ‘psychosomatic’ has many connotations. Psychosomatic medicine is first of all a theoretical concept as described by Meyer [1, 2], von Weizsäcker [3], Engel [4, 5] or Fava and associates [6–9], which is synonymous to the biopsychosocial concept in medicine, and which is also underlying the ICF (International Classification of Functioning, Disability and Health) of the World Health Organization [10]. Some scientists use it to describe what every physician should do when dealing with a patient, i.e. not look at the illness only but at the patient as a suffering individual [11]. For others it is the treatment of somatic illnesses by psychological methods and interventions [12]. Some understand psychosomatic medicine as the treatment of somatoform disorders, i.e. mental illnesses which express themselves by unexplained somatic symptoms [13]. It is also used synonymously for patient education and helping patients to cope with their Prof. Dr. Michael Linden Rehabilitation Center Seehof Lichterfelder Allee 55 DE–14513 Teltow/Berlin (Germany) E-Mail michael.linden @ charite.de
illness, be it in the individual physician-patient encounter or in structured educational groups [14]. Another definition is found in ‘basic psychosomatic care’ which is a type of limited psychotherapy and which can only be applied after a special training and licensing in some countries like Germany [15]. Psychosomatic medicine is also used synonymously with structured psychotherapy [15]. There are also medical specialties like ‘specialists for psychosomatic medicine and psychotherapy’ with a 5-year training and official licensing [16]. Finally, there are ‘psychosomatic inpatient facilities’ in acute and in rehabilitation hospitals [17]. Based on the theoretical framework of biopsychosocial medicine and the corresponding definitions of ‘psychosomatic medicine’ [6–8], this paper will give an example of how this concept can be translated into practical patient care. This will be done with reference to psychosomatic medicine as practiced in ‘psychosomatic rehabilitation hospitals’ in Germany.
The Psychosomatic Rehabilitation System in Germany
As psychosomatic inpatient rehabilitation units are a German peculiarity, it is first necessary to describe this type of health care system. This also includes an explanation of the meaning of rehabilitation, which is a biopsychosocial approach in itself and therefore has also a direct significance for the practice of psychosomatic medicine. According to the German Social Law (SGB IX), all negative health states which last longer than 6 months and which are associated with present or impending restrictions in social or occupational participation are called disability and are subject of rehabilitation. In addition to vocational rehabilitation and other forms of social support, there is also ‘medical rehabilitation’ which, according to the law, aims at the primary prevention, treatment, compensation and secondary prevention of chronic illness and which has to use all available medical means like treatment by physicians, psychotherapy, medication etc. In the first place, this type of care is reimbursed by health insurance or state social security. If early retirement is pending, the pension insurance agency steps in to prevent ill-health retirement. The first inpatient ‘psychosomatic’ hospital in Germany was founded in 1929 by V. von Weizsäcker und L. Krehl in Heidelberg. The first psychosomatic rehabilitation hospitals started with a psychodynamic orientation in the sixties, and behavior therapy units followed in the 206
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Table 1. Characteristics of the therapeutic milieu in inpatient psychosomatic rehabilitation
Improved diagnosis Intensive treatment Shelter Relief of demands and burdens Structuring of the day Therapeutic demands Practice field Motivation Model learning Contact with others Reliable observation for expert assessment of the illness state, prognosis and ability to work
seventies. Today there are about 25,000 beds in inpatient rehabilitation units in Germany or 0.3/1,000 persons of the general population. These psychosomatic rehabilitation units take care of about 200,000 patients/year, i.e. 2.5/1,000 of the general population or about 5/1,000 of those in the working age group. Patients themselves or their treating physicians can apply for inpatient rehabilitation. A major part of patients is sent to inpatient treatment by the health insurance company after being on sick leave for few weeks or by the pension insurance company when they apply for early retirement [18]. Because of this way of referral, patients are suffering from all types of mental illness. There are also patients who would never have asked for treatment if they had not been sent in by an insurance company and who may therefore suffer from so far undiagnosed problems. Before admission the treating physicians have to write a case report which is reviewed by physicians of the insurance company, who have to approve the admission and also select the hospital. The length of stay , in most cases 5 weeks, is set from the beginning by health and pension insurance agencies before admission of the patient, and can only be shortened or prolonged in special cases. Patients are sent to hospitals throughout the country, because all units have specialties which are known to the insurance companies. There are rehabilitation hospitals which are specialized in addiction, eating disorders, schizophrenia, borderline disorder or pain. Most will also treat depression, anxiety disorders or somatoform disorders. These patients with chronic mental disorders are sent to inpatient units because of the advantages of treatment in a ‘therapeutic milieu’ (table 1). This includes distance Linden
ICD
ICF
Therapy
Complaint, symptom
Disorder of function
Treatment of symptoms
Diagnostic algorithm
Limitation of capacity
Training of capacities
ICD-10 diagnosis
Context
Change of context
Sickness status Restriction of participation
Social support (e.g. pension) Salutotherapy
Treatment permission
Fig. 1. ICD, ICF and psychosomatic treat-
ment goals.
from daily burdens, structuring of the day, model learning, or intensive and comprehensive treatments [19]. It is also of importance that at the end of the stay the insurance company expects a medical report on the ability to work or the degree of impairment [20–22]. Inpatient treatment allows more thorough evaluations than short-term ambulatory assessments.
Treatment Goals of Psychosomatic Rehabilitation according to the ICF
The underlying theoretical guideline of inpatient psychosomatic rehabilitation is the biopsychosocial model of the ICF [10, 23]. This includes diagnoses according to the ICD-10. However, these diagnoses alone cannot tell how to treat a patient. Treatment is targeting and guided, in the terminology of the ICF, by ‘disorders of functions’, i.e. symptoms, ‘limitations in capacity’ and ‘restrictions of participation’. Finally, ‘restrictions of participation’ occur when the personal or environmental context and individual capacities are not in accordance. Figure 1 gives an overview on the relation between ICD and ICF. Complaints are translated by diagnostic algorithms into diagnoses, which are a prerequisite for treatment. Medication without a diagnosis is doping, whereas with a diagnosis it is therapy. Complaints of patients, in contrast to complaints of healthy persons, are Psychosomatic Inpatient Rehabilitation
‘symptoms’ or ‘disorders of function’ according to ICD [24] and ICF [10]. The goals of treatment can be structured and classified according to the biopsychosocial model of the ICF. The first goal of any treatment is to reduce symptoms or restore functions, like concentration, emotional state, formal thinking, or drive. If this cannot be achieved, the second goal is to improve capacities. Examples are assertiveness or social competency. If then there is still an insufficient coping with daily life, e.g. inability to work, the third goal is to modify the context, i.e. work demands, so that the impaired person can still participate in daily life. Finally, if nothing more can be done, there are still the goals of protecting or improving quality of life and well-being and of providing social security, e.g. by granting a pension or sheltered living. In summary, treatment goals take into account the present type and severity of illness, but go far beyond and focus also on psychological and social aspects, i.e. take a holistic view on the patient and his living situation. This broadened view is of less relevance in acute illness episodes but indispensable in chronic illnesses where their impact on well-being, coping with daily demands and living conditions often has more negative consequences for the patient than the symptoms of illness as such. Rehabilitation medicine is therefore inevitably biopsychosocial or psychosomatic in the general sense of the word.
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Diagnosis and treatment of illness
Diagnostic reassessment
Curative and/or palliative treatment
Prophylaxis
Training of capacities
Coping with illness
Long-term medical care
Treatment compliance
Disability benefits
Coping with disability
Chronic illness, quality of life, participation
Occupational participation
Self-concept
Lifestyle
Assessment of disability
Work reintegration, social assessment
Social net
Activities of daily living
Well-being
Salutotherapy, compensation of illness
Fig. 2. Therapeutic interventions in psychosomatic inpatient rehabilitation.
Inpatient Psychosomatic Treatment Process
These multiple treatment goals have to be translated into a multidimensional and multidisciplinary treatment process. As the average duration of the inpatient stay is about 5 weeks, treatment has to be planned so that adequate results can be achieved in this short period of time. Figure 2 gives an overview of what is done under a psychosomatic perspective. The first task in inpatient psychosomatic rehabilitation is to review the diagnosis according to ICD/DSM algorithms [24, 25] but also to a more comprehensive psychosomatic perspective [9, 26, 27]. Most prevalent are mood disorders, anxiety disorders, adjustment disorders, somatoform disorders and personality disorders, which is similar to the spectrum of mental disorders in the general population or in primary health care [28] and different from psychiatric acute care hospitals. Such chronic psychological disorders are often diagnostically ambiguous and multidimensional, e.g. a patient may complain about depressed mood and look as if he were suffering from a depressive illness while in fact the problem is sleep apnea, alcohol abuse or just unhappiness [29]. 208
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Because of the specialties of admittance there are furthermore types of disorders which will not be seen in other psychiatric institutions or are not described or covered in ICD [24] or DSM [25]. Examples are embitterment reactions, work phobia, resilience deficit syndromes, mild cognitive dysfunctions, demoralization or irritable mood [9, 30–38]. Assessment also includes a functional analysis of interactions between mental disorder, personality and environment [39]. In some cases, new diagnostic insights, including a broadened view on life events and psychosocial factors, open the way to new and effective treatments. The question to be answered is whether the present negative health status is chronic or only pseudochronic. Chronicity is defined as persistence of symptoms in spite of intensive treatment efforts [40, 41]. Because of the specialization of rehabilitation units there are, for example, some with dozens of anorexia patients at a time, which allows interventions beyond what is possible in regular outpatient care [17, 27]. Treatment includes medication and other somatic treatments and most of all psychotherapy. Psychosomatic rehabilitation hospitals all have a high psychotherapeutic expertise, be it psychodynamic or cogniLinden
tive-behavioral. Patients regularly get single and group psychotherapy. They are additionally treated by sport therapists, occupational therapists and social workers. This allows complex treatment regimens. A patient with hypochondriacal cardiac problems will be seen by a physician and get a medical workup; he will then be treated in single and group psychotherapy to learn anxiety management. He will get exposure treatment in sport therapy. In occupational therapy he will learn to distract himself from anxiety and engage in compensatory activities and enjoy life, and will get support by social workers on how to find his way back to work. Treatment also includes prophylaxis of recurrent episodes or illness deterioration. This can be prophylactic medication and/or prophylactic psychotherapy. Many psychotherapies like ‘well-being therapy’ [42, 43] have been shown to have prophylactic effects even in primarily treatment-resistant cases. In addition to the treatment of symptoms or disorders of function, another level of interventions aims at improving capacities or coping ability. There are well-established and evidence-based treatments to improve such capacities. Examples are problem-solving capacities [44], assertiveness and social competency [45], time management [46], stress management [47], flexibility [48] or work hardiness [49]. Such capacities can help to ameliorate retroactively symptoms but, more importantly, they decide about secondary consequences of illness and social or occupational participation. If the illness cannot be cured, the next important treatment goal is to help the patient cope with the illness and chronic impairment and improve ‘illness behavior’ [50, 51]. Patients have to adapt health attitudes, accept and support treatment and learn to adjust their lives to the chronic illness. Apart from general patient education and improvement of patient compliance, an important general treatment concept is the SOC (selection-optimization-compensation) paradigm from Baltes [52]. It encompasses ‘selection’ of what can still be done in spite of the chronic state of illness. This should be ‘optimized’ by training and it should be ‘compensated’ what can no longer be done. Patients with personality disorders, for example, are invited to look in detail for their strengths and then make the best out of it, while trying to compensate what leads to misunderstandings [38]. A third area of interventions aims at the improvement of quality of life [53]. Most chronic illnesses impair the subjective well-being, contentment with life, daily activities, leisure activities or social contacts. There are patients who have not been to a cinema for years, because they did Psychosomatic Inpatient Rehabilitation
Table 2. Therapeutic interventions to support work reintegration
Individual psychotherapy to improve self-efficacy, reduction in anxiety, etc. Competency training by occupational therapists (concentration, endurance, functional training) Special group therapies: conflict management at the workplace, work hardening, etc. Internet search for new job opportunities Application for jobs with the support of therapists Counseling for occupational rehabilitation Individual counseling for work-related problems Contacts with the employer Training at workplaces during inpatient stay Group psychotherapy after the inpatient stay for up to a year Follow-up counseling
not feel like it. To safeguard or improve healthy areas of life or quality of life is often more important than to change symptoms of illness. There is a broad spectrum of evidence-based interventions which can be summarized under the heading of ‘salutotherapy’ [54–56]. Examples are to support self-care, or increase daily, cultural or creative activities. Most important is it to safeguard the social net and foster social encounters [57, 58]. Another important area of treatment interventions aims at helping patients to cope with work demands or find their way back to work [59–64]. During recent years pension insurance has stimulated rehabilitation centers to put more emphasis on this part of treatment (table 2). This starts with looking at illnesses from a participation perspective instead of from a pure symptom orientation. An example is anxiety in relation to the job, i.e. workrelated anxiety and workplace phobia [35, 36], which can be differentiated from anxiety in general. Workplace phobia is a disorder which is especially suited to explain the biopsychosocial approach in psychosomatic medicine: any workplace is full of possible anxiety-provoking features like superiors with their demands and evaluations, colleagues and rivalries, aggressive customers, health threats or job insecurity. Workplace-related anxiety or even workplace phobia need special attention and psychotherapeutic strategies. First of all there are pharmacological and psychotherapeutic ways to ameliorate the level of general anxiety. Exposure treatment can be supported by practical training in some real-life workplaces, where patients are sent to during their inpatient stay. Patients can go back to their own workplace after discharge from hospital in a graded manner, starting with few hours per day and then increasing their presence at Psychother Psychosom 2014;83:205–212 DOI: 10.1159/000358852
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work in a stepwise manner. If there are conflicts at work, therapists can contact the parties involved and try to solve the problem. If patients can no longer fulfill regular work demands, the employers are contacted in search for a workplace suitable for the patient. Patients with social anxiety can be transferred to an office instead of working with clients. Some patients need support in finding new work, be it by applications for employment or by finding new occupational perspectives. They can be transferred to occupational training. There is also the opportunity to participate in group treatment for about a year after discharge from hospital, which is paid by the pension insurance and aims at improving work participation. If the ability to work cannot be reinstalled, social support has to be found and initiated. This can be sickness compensation or pension or welfare benefits. Finally, all patients have to be guided to find adequate long-term treatment and care after discharge from hospital [27]. This can be self-help groups, contact to counseling institutions, treatment and guidance by general practitioners or ambulatory specialists, specialized ambulatory psychotherapy or disease management programs.
Quality Assurance, Effectiveness and the International Perspective
The system is subject to close monitoring and quality assurance by the pension agency. All therapeutic interventions are coded according to a classification scheme for therapeutic interventions [65] and reported to the pension insurance company, which controls the duration of inpatient stays. They overview the number and qualification of the personnel, they make regular visits and talk to patients and therapists, they undertake standardized peer review assessments of physician’s letters and medical reports, they collect and report the number of patient complaints, and send a feedback questionnaire to a sam-
ple of patients weeks after dismissal. Finally, the pension insurance company has all data on the working status of patients in the years before and after medical rehabilitation. The primary outcome of inpatient rehabilitation is a valid expert judgements on whether patients are able or unable to work and deserve ill-health retirement or not. Additionally it is also of interest whether the health status of patients can still be improved. There are several studies on positive effects with respect to improvement of the medical and psychological status of patients, their social impairment, the motivation to work, the number of days on sickness absence, reduction of early retirement and occupational reintegration [59, 60, 66–80]. An important outcome parameter is that the system saves money for the pension insurance. The costs for inpatient rehabilitation are about EUR 130 per day, i.e. about EUR 4,000–5,000 in total. The pension insurance agency has a direct financial benefit when patients stay at work for only 3 additional months. A proof for the effectiveness of psychosomatic rehabilitation is that the pension insurance agency, which has all pertinent data, has continuously implemented more and more rehabilitation facilities over the years [20, 76–79]. This system of inpatient psychosomatic rehabilitation is unique in the world although some other countries have started similar projects in recent years like Poland or Austria, where the number of respective facilities has also grown up to 100% during the last few years. The psychosomatic rehabilitation hospitals make an important contribution to the health care of patients with chronic mental disorders, supplementary to acute inpatient care and ambulatory care. Rehabilitation hospitals allow a unique access to special patient groups and medical problems which are not seen in other health care facilities, which provides opportunities for research or medical education.
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