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DOI 10.1007/s10591-013-9267-1
ORIGINAL PAPER
Abstract The roots of systemic therapy in Germany date back to the sixties. Systemic
therapy is one of the most widely applied forms of psychotherapy and counseling in
Germany. The majority of therapists and counselors in child guidance centers, couples
therapy counseling centers and youth protective services have been trained in systemic
therapy. A high number of clinical psychologists, social workers and medical doctors have
received training in this model of therapy. In the beginning, multigenerational, experiential, as well as structural-strategic and Milan systemic approaches were popular. Today, the
post-modern systems concepts, solution-oriented and narrative approaches and self-organization theory appear to be predominant. Some centers provide research and training in
behavioral and psychodynamic family and couples therapy. However, systemic approaches
are clearly leading the field with over 10,000 people who have received systemic training
and about 150 training institutes across the country. The critical attitude shared by many
leading figures towards empirical research has limited its success in university programs.
In addition, training is usually provided in the form of post-graduate courses rather than at
academic institutions. Currently, three journals and one online-journal publish articles on
various systemic topics. Many publishing houses have a series of books on systemic
therapy and one publishing house specializes exclusively on systems oriented books. In
2008, systemic therapy gained recognition as an evidence-based treatment. Four years
later, the appropriate authorities have not initiated the process of assessing it as a treatment
paid for by public health insurances. In consequence, systemic therapy is not available on a
large scale in the public outpatient psychotherapy system. Some additional remarks are
provided on the history and current situation of systemic therapy in Austria and
Switzerland.
Keywords
R. Retzlaff (&)
Director of the Clinic of Marital and Family Therapy, Institute for Collaborative Psychosomatic
Research and Family Therapy, Heidelberg University Hospital, Bergheimer Str. 54, 69115 Heidelberg,
Germany
e-mail: Ruediger_Retzlaff@med.uni-heidelberg.de
URL: http://www.med.uni-heidelberg.de/psycho/pfam; http://www.ruediger-retzlaff.de
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The 1980s
In the 1980s, during the aftermath of what is called the second cybernetics, the systemic
field moved away from structural-strategic, multigenerational, and experiential approaches.
In accordance with ideas by Dell, Maturana, and Varela. Nicolas Luhmann presented a
sociological systems theory in 1984 which continues to be highly influential in Germany.
Distinguishing between the three classes of autopoietic systems: organismic life, consciousness, and communication, which are intertwined yet independent, Luhmann maintained that systems can neither be predicted nor be influenced in a directive, linear way.
In 1985, Manfred Vogt who had trained in Heidelberg, started to offer solution-oriented
therapy at his training institute in Bremen. In the subsequent years, Steve de Shazer, was
regularly invited as a trainer by him, well as by Gunther Schmidt in Heidelberg.
In 1987, Marie-Luise Conen founded her training Institute in West-Berlin. She had
studied at Temple in Philadelphia and participated, together with the author of this article
in the last training with Boscolo and Cecchin at the IGST. Over time, she invited a large
number of American, British, and Italian pioneers to teach at her institute. Based in
structural and Milan systemic approaches, she published a large number of articles and
books on families in poverty, systemic therapy within residential centers for children and
adolescents, and home-based family therapy. Conen has to be credited for first establishing
home-based family therapy in Berlin. After changes in social legislation throughout the
country, it is now routinely offered by most Child Guidance Centers and by many youth
protective services (Conen 2002).
The 1990s
When Stierlin retired in 1991, there were plans to close his department and integrate it into
the Psychiatric and the Psychosomatic University Hospital. At this time, Jochen Schweitzer
moved to the Department of Medical Psychology at Heidelberg University Hospital. In the
department of family therapy, he was succeeded by the author, who continued to run the
outpatient clinic and courses in systemic family therapy from 1995 forward. Since that
year, the Clinic of Marital and Family Therapy has provided systemic therapy, especially
for families with medical concerns (Retzlaff 2010). The author received post-graduate
training in MFT at the institute of Kirschenbaum, with supervision from the MRI group.
He also had training at the Philadelphia Child Guidance Clinic, as well as from Boscolo
and Cecchin. He has worked with Hans Jellouschek and Roland Weber in Stuttgart and
trained with Fritz Simon, Gunther Schmidt, Gunthard Weber, Ingeborg Rucker-EmbdenJonasch, Welter Enderlin, and Hunter Beaumont. After intensive lobbying by Gunthard
Weber and others, in an unprecedented move, the state secretary of science and education
insisted that a new professor of family therapy must be hired, overruling the autonomy of
the university for the first time in decades. He strongly urged the university medical school
to maintain the department of family therapy and to appoint a family therapist as the chair.
In 1998, Cierpka, the successor of Sperling at Gottingen University Hospital, who had had
been trained as a psychoanalyst in Ulm, became the new chair of the renamed department,
with the long name, Institute for Collaborative Research and Family Therapy. Cierpka
became known by the German version of the family assessment device, a handbook of
family diagnostics (Cierpka et al. 2005) and for his work on family therapy with eating
disorders. Cierpka and the author share an interest in family systems medicine and together
published a textbook on this topic (Cierpka et al. 2001). In the subsequent years, the
department has been highly successful with a series of high-profile, highly visible
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programs such as the German version of Second Step, parent-infant therapy according to
the model developed by Papousek, and an early intervention program for high risk families
with infants. In 2000, Astrid Riehl-Emde, a psychodynamic and systemic couple therapist
who had worked with Jorg Willi in Zurich, joined the department and started projects on
marital therapy with elderly couples.
In 1992, Kurt Ludewig founded a systemic institute in Hamburg and published one of
the first textbooks on systemic therapy. Two years later in 1994, Jurgen Kriz, from the
University of Osnabruck, applied post-Milan ideas and Rogerian concepts to the practice of
systemic therapy. All of these changes resulted in a strong bias towards cognitive and
verbal phenomena in systemic therapy. It also brought extreme skepticism towards any
form of empirical research, which was considered to be an epistemological error. This view
is still held by the majority of leaders in systemic therapy in the country and as a consequence, it makes it rather difficult to succeed in the academic field.
In 1996, von Schlippe from the University of Osnabruck and Schweitzer, published a
successful textbook on systemic therapy, which is virtually read by anyone interested in
systemic therapy. This textbook received 10 editions and has been translated into a variety
of languages (von Schlippe and Schweitzer 2012). It describes all systemic approaches,
particularly solution-oriented therapy, narrative approaches and self-organization theory.
Less credit is paid to more traditional family therapy approaches including structuralstrategic approaches which were considered to be old-fashioned, which means that a
generation of systemic therapists have been trained with comparatively little knowledge of
the more pragmatically oriented schools of systemic therapy. A second textbook on systemic treatment of various disorders by the authors (Schweitzer and von Schlippe 2006)
received much praise and some criticism, as some systemic therapists consider it to be
inadequate to take a nomothetic position as a systemic therapist.
Realizing that non-directive play therapy is more effective if the family is involved in
treatment, Schmidtchen (1999) from Hamburg developed an integration of Rogerian and
systemic family therapy.
As in the USA in the 1990s, feminist issues in family therapy were widely discussed and
two members of the IGST (Rucker-Embden-Jonasch and Ebbecke-Nohlen 1992) addressed
the related issues in writing and teaching.
In the German Democratic Republic, Scholz had started to work with families in the
Dresden Hospital of Child and Adolescent Psychiatry even before the unification of the two
German states. His interest intensified after the family therapy conference in Hungaria in
1988 where he met Minuchin, Stierlin, Weber and many others. Together with Eia Asen
from London, he pioneered multi-family groups for young anorexic patients, and this
format is now widely used, including countries such as Sweden and Norway.
For more than a decade, clinical psychologists had pushed for a better status in the
public health care system. Two publications were highly important for the destiny of
systemic therapy and its position in the health care system. In a report to the Federal
Ministry of Health Affairs, published by Klaus Grawe together with psychodynamic
researchers, behavior therapy, psychodynamic therapy and psychoanalysis were recommended as evidence-based treatments but systemic therapy was not (Meyer et al. 1991). In
a more concise meta-analysis, Grawe et al. (1994) concluded there were not enough studies
supporting systemic family therapy as an evidenced-based treatment, stating instead that
there were promising data and the status might be different if more studies were available.
Grawe et al. were also highly critical about the evidence base of psychodynamic therapy
and psychoanalysis, much more critical than in the 1991 government report in which
Grawe had co-authored.
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Fischer, Gester, and Clement remained in the IGST. With support from Stierlin, Simon,
Schmidt, Weber, the late Rucker-Embden-Jonasch, Schweitzer and Ebbecke-Nohlen
founded the Helm Stierlin Institute (HSI) in Heidelberg, and later invited Nicolai, KindlBeilfuss, Reinhard and the author to join the HSI, which continues to operate as a highly
visible, successful post-graduate training institute.
Another more recent trend is an increasing interest in children and adolescents in
systemic therapy. With the largely verbal and cognitive orientation of systemic therapy in
the 1980s and 1990s, children somehow vanished from popular textbooks, and their needs
were not adequately addressed in training. After a few critical articles on the neglected role
of children in systemic therapy, the author published a series of articles and initiated a
special curriculum of systemic therapy with children and adolescents. Therapists such as
Wilhelm Rotthaus, Manfred Vogt, and Therese Steiner have published numerous books on
systemic therapy with children. A textbook on this topic by the author has received five
editions within just 4 years (Retzlaff 2012).
In recent years, along with changes in social structures and parenting styles, similar to
many other countries, parental helplessness became an issue in Germany. von Schlippe
started to invite, teach and publish with Haim Omer, a Brazilian-born psychologist who
now teaches in Israel. His ideas about coaching of parents became rather popular among
German systemic therapists because of its non-authoritarian stance. Ironically, while the
work of Minuchin is largely ignored today, rather similar concepts have been re-introduced
by this approach (Omer and von Schlippe 2003).
Only gradually does the German society realize the challenge posed to the health care
system by migration and the high number of citizens who have migrated to Germany.
Currently, about 35 % percent of children and adolescents have parents who were not born
in the country. Consequently, the number of publications on culturally sensitive systemic
therapy is on the rise (von Wogau et al. 2004).
In 1985, Helm Stierlin visited and taught systemic therapy in China. The ChineseGerman Academy of Psychotherapy (Deutsche-Chinesische Akademie fur Psychotherapie)
promoted regular trainings in systemic (and other forms of psychotherapy) and in the past
decades, a considerable number of systemic trainers volunteered to work in the Baltic
States, Poland, Slowenia, and other countries in Eastern Europe.
Couple and marital therapists in Germany tend to be an integration of systemic,
humanistic, and some psychodynamic and behavioral elements. Only recently, emotionally-focused therapy is becoming more known in Germany, and Volker Thomas from the
University of Iowa has carried out the first training workshops at the Department of
Collaborative Research and Family Therapy in Heidelberg in 2010 and 2011.
In 2004, after joining AFTA and participating in the Miami conference on children in
family therapy, the author brought home the idea that there are indeed a sufficient number
of randomized controlled trials (RCT) on systemic therapy to convince the WBP to recognize it as an evidence-based treatment. Together with Stefan Beher, a talented young
masters degree student, and Jochen Schweitzer, he founded a working group which was
joined by Kirsten von Sydow, formerly from the University of Hamburg, who had compiled a similar number of RCT on the effectiveness of systemic therapy, in order to get
recognized as an evidence-based treatment approach. In the beginning, the DGSF and SG
were highly reluctant to pursue another attempt for scientific recognition. As a matter of
fact, at a 2004 conference in Potsdam, the SG had even discussed dropping any attempt to
gain scientific recognition as meaningless. Then, an official of the internal revenues office
requested payment of 17 % value added tax from systemic training institutes, on the basis
that they did not provide education in a form of scientifically recognized psychotherapy
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(which is tax exempt) and rapidly, the professional organizations supported the working
group. The group prepared a series of articles and scientific reports to the Board of
Scientific Examiners in Berlin (von Sydow et al. 2006, 2007a, b, 2010). Kirsten von Sydow
was invited to present the evidence-base as a deputy member of the board, without formal
right to vote. In the meantime, the author continued to find additional RCT with support
from Beher, Schweitzer and a number of doctoral students. The authors idea to search in
Chinese databases with the help of Zhao Xudong from Tongji University in Shanghai and
Joyce Ma from Hong Kong, and Chinese doctoral students working at our departments was
a breakthrough. Eventually, in December 2008, the president of the WBP declared systemic therapy to be an evidence-based treatment. Ironically, this was the same person who
had wanted to close Stierlins department in Heidelberg. In the past 4 years, the author has
continued to work and publish on the evidence-base of systemic therapy in order to meet
the requirements of the German health insurance systems (Retzlaff 2009a, b). von Sydow
now teaches at the Psychological University in Berlin (PHB).
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systems therapists as well as post-graduate training programs rely more on German language books than on books in English, which were previously used in the 1970s and 1980s.
Conferences
In 1994, Bernhard Trenkle brought the Evolution of Psychotherapy Conference to Hamburg, and a large number of therapists had a first-hand chance to meet many of the
international pioneers of family therapy. Trenkle organized other important conferences on
family therapyfor instance, one held in Karlsruhe with pioneers of the field, (1988) one
in Heidelberg (2004) with Minuchin, in cooperation with the Department of Family
Therapy. A popular conference is Trenkles Kindertagung, a conference on hypnotherapy and systemic therapy with children held every 4 years in Heidelberg.
Both DGSF and SG conduct annual conferences, with 3001200 and 300600 participants, respectively. Every 4 years, Trenkle organizes a conference in Heidelberg on
hypnotherapeutic and systemic approaches for children and adolescents, with about 1,200
participants. The biannual systemic research conference organized at Heidelberg University Hospital by Schweitzer attracts about 180300 people. In 2004, Ludewig organized the
EFTA-conference in Berlin, which was visited by way over 5,000 participants.
Systemic and Family Therapy Within the Current Medical and Social Services
Systems
In 2005, approximately 10,000 therapists had received a systemic training certificate. In
different German states, between 16.5 and 37 % of licensed psychotherapists have also
been trained as systemic therapists, and 55.9 % of counselors at child guidance centers are
systemic family therapists (von Sydow et al. 2007a, b).
Counseling services to adults including couples counseling are provided by agencies run
by charity organizations of the churches or other welfare organizations child guidance
work and child protective services are provided in counseling centers run by the cities or by
charity organizations, which are regulated by the Federal Children and Youth Protective
Services Act. They are funded by the administration of cities and counties. The vast
majority of people working in child guidance centers and the youth protective agencies
have obtained systemic training.
Health care servicesincluding psychotherapyfor people with and without a job are
being paid for by public health insurances and regulated by federal law. State employees
and people with a higher incomes can opt for private health care organizations which are
regulated to a lesser extent by federal law. When clinical psychologists gained access to the
public health insurance system in 1999, after an initiative by the Federal Minister of Public
Health who happened to be a professor of psychology from Heidelberg, only psychodynamic therapy, psychoanalysis and behavior therapy were considered to be evidence-based
treatments, but systemic therapy was not included on that list. Today, therapists may treat
patients with behavior therapy or psychodynamic therapy and involve relatives, but they
must not call it systemic or family therapy. Systemic (family) therapy is not covered by
health insurances, but it can be provided in inpatient settings.
To legally practice any form of psychotherapy, a state license either as an MD, as
clinical psychologist/psychotherapist or as a child and adolescent psychotherapist is
required. To regulate the thriving market of alternative medicine, there is another, legally
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inferior license as a health practitioner, many of whom offer some form of systemic
counseling. Medical doctors can specialize as a psychiatrist, child and adolescent psychiatrist or as a doctor in psychotherapeutic medicine, with 240 h of theory and four cases
treated with family therapy. This training clearly is insufficient to learn how to treat
families. Psychologists, after a bachelors and masters degree, receive 600 h of courses in
theory and 2,800 h of clinical practice. In addition, they will have about 812 h theory in
family and couple therapy. This also applies to training as a child and adolescent psychotherapist, which is also open to various professions with a masters degree who work
with children (i.e. educational specialists, etc.).
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Conclusion
Systemic therapy has a long and diverse history in Germany. In contrast to the high number
of systemic therapists and post-graduate training institutes, the position within the system
of public health care remains dissatisfying. With the increasing pressure towards effective
treatments, large public health insurances will favor approaches which are resource-oriented, and provide short-term outpatient therapy instead of expensive inpatient treatment.
Systemic practitioners and the systemic professional organizations should be in an
excellent position to meet this challenge by offering various forms of systemic services, in
order make a valuable contribution to the German health care system.
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