Development of Family Therapy and Systemic Therapy

Contemp Fam Ther (2013) 35:349–363 DOI 10.1007/s10591-013-9267-1 ORIGINAL PAPER

Development of Family Therapy and Systemic Therapy in Germany Ru¨diger Retzlaff

Published online: 16 April 2013 Ó Springer Science+Business Media New York 2013

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

Family therapy Systemic therapy Germany History

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: [email protected] URL: http://www.med.uni-heidelberg.de/psycho/pfam; http://www.ruediger-retzlaff.de

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Contemp Fam Ther (2013) 35:349–363

A Brief Overview of the History of Family Therapy in Germany The 1960s Similar to the USA, psychoanalysts played an important role in the development of family therapy in Germany. Many people hold the view that it was introduced in our country by Helm Stierlin. Yet in 1963, Horst-Eberhard Richter, who worked at Gießen University Hospital, published a book on family therapy from a psychoanalytical perspective (Richter 1963). He did not become interested in systems concepts and did not pursue family therapy to a larger extent (Richter 1970). Rather, Richter became involved in group therapy and the application of ideas from psychotherapy to political affairs and social politics. In 1965, Eckhard Sperling, a child and adolescent psychiatrist from Go¨ttingen University Hospital presented his work on the family dynamic of adolescent anorexic patients for the first time (Sperling 1965). He later founded a psychodynamic-systemic integrative model (Sperling et al. 1982). Experiential approaches to family therapy were quite compatible to views held by many humanistic therapists. In the late 1960s, Gerd Mu¨ller, who originally had done research on behavioral parent training programs at the Max Planck Institute of Psychiatry in Munich, became interested in family therapy (Mu¨ller and Moskau 1983). Together with Gaby Mu¨ller, a Canadian social worker raised in a Czech-German-Jewish family in Prague, who had survived a number of concentration camps as a young girl, he started to invite Virginia Satir and the Duhls for workshops. He founded the first formal family therapy training institute in 1974 in Germany in Munich, which stills exists today. Around the same time, Martin Kirschenbaum and Carol Gammar started to teach family therapy in various cities across the country and continued to do so for many years. Maria Bosch, who had received her family therapy training from Satir, Kempler and McClendon, also invited Satir and the Duhls for conferences and workshops. She founded her highly successful family therapy institute in Weinheim in 1974 (Bosch 1983). However, in 1985 she withdrew and started to teach at her new training center in Weinheim. The 1970s In the early seventies, a group of behavior therapists—Ludwig Schindler, Kurt Hahlweg, and Dirk Revenstorf—conducted research on behavioral couple therapy at the Max Planck Institute of Psychiatry in Munich (Schindler et al. 1980). Hahlweg had spent a year at the Department of Psychology and Neuropsychiatric Institute in Los Angeles and worked until his retirement at the University of Braunschweig. There he conducted research on behavioral couple therapy, expressed emotion, and behavioral family therapy approaches in the treatment of severe mental disorders such as psychosis and bipolar disorder (Hahlweg et al. 2000). The key event for the development of systemic family therapy in Germany was the foundation of the Department of Psychoanalysis and Family Therapy by Helm Stierlin in 1974. He had accepted the position as the first and to this day only university chair of family therapy in the entire country. Since 1957, Stierlin had worked in the USA, mostly in Chestnut Lodge/Maryland. After an interlude from 1963 to 1965 in Switzerland and study periods in New Zealand and Australia, Helm Stierlin became a member of the National Institute of Mental Health, where he worked together with Lyman Wynne and Margaret

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Singer. He was invited to Heidelberg by psychoanalysts, but differentiated quickly by quoting in his introductory lecture at the University of Heidelberg Haley’s work on his understanding of psychoanalysis (Duss-von-Werdt 1991; Stierlin 2001). Stierlin attracted a group of highly talented young people. All of them were to become the leading group of systemic therapists in the country in the subsequent years. Throughout the years, a number of brilliant and successful people worked in his department for some time. Characteristic for Stierlin’s style of leadership was the encouragement of individuality of his team members. His first team consisted of the late Ingeborg Ru¨cker-EmdenJonasch, Fritz Simon, Gunthard Weber, and Michael Wirsching. Wirsching later moved to Gießen, and then to University Medical School in Freiburg where he now teaches as professor of psychosomatic medicine. For a long time, he was the only disciple of Stierlin who held a regular chair as university professor. Gunther Schmidt and Bernhard Trenkle, two former students of Stierlin, joined his group and were later replaced by Arnold Retzer, Andrea Ebbecke-Nohlen and Jochen Schweitzer. Schweitzer had been an intern for a year at the Cambridge Guidance Center at Harvard Medical School. All members of the Department of Psychoanalytical Basic Research and Family Therapy published extensively, particularly on family therapy for clients with anorexia nervosa, psychosis, and family dynamics in general (Stierlin 1978; Stierlin and Simon 1984). Stierlin attracted high numbers of students to his lectures. Additionally, he and his wife Satuila Stierlin invited most of the leading family therapists from the USA and Europe to Heidelberg. Originally starting as psychoanalysts, under the influence of the Milan group, Stierlin and his department shifted away from psychodynamic concepts to Milan style systemic therapy. In 1983, Stierlin and his associates founded a private training institute, Internationale Gesellschaft fu¨r systemische Therapie (i.e. IGST: International Society of Systemic Therapy). This institute started a highly successful postgraduate training in systemic therapy and a series of large international conferences. For many years, members of the Milan group and Boscolo and Cecchin in particular came to Heidelberg to teach at the IGST. While the IGST was a key to disseminating systemic therapy in Germany, training activities withdrew energy from university matters. As a result, Stierlin invested less time on internal university politics, which was to have serious consequences for the future of his department. In subsequent years, Gunther Schmidt and Bernhard Trenkle, who had briefly been affiliated with the department of Helm Stierlin, became interested in the work of Milton H. Erickson and founded their own Ericksonian training institutes. ‘‘Hypnosystemic therapy’’ is an integration of systemic therapy, hypnotherapy and self-organization theory. It has become a mainstream form of systemic therapy in Germany, which is also widely applied for use with individuals in therapy (Schmidt 2004). While systemic therapy in Germany has been shaped by postmodern approaches, Trenkle remains, apart from the author, the trainer with the strongest affiliation to strategic concepts of Haley and Madanes. Another influential hypnosystemic therapist, with a strong experiential touch, is Nemetschek (2006). He trained with Satir and M. H. Erickson and later founded a training institute in Munich in 1978. One of the first trainees at the Weinheim Institute was Hans Jellouschek, who founded with his late wife the Family Treatment Center at the Center for Psychotherapy in Stuttgart. As a close friend of Rosmarie Welter-Enderlin, he developed a humanistic-systemic form of couple therapy and published more than sixteen extremely popular books on couple therapy. This made him the most influential couple therapist in the country (Jellouschek 2005; Welter-Enderlin and Jellouschek 2002).

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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 Ru¨cker-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 Go¨ttingen 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 Jo¨rg 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, Ju¨rgen Kriz, from the University of Osnabru¨ck, 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 Osnabru¨ck 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 (Ru¨cker-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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In an attempt to gain recognition as an evidence-based treatment, Schiepek (1999) published a somewhat imprecise report on randomized trials on systemic therapy. This report was submitted by the German Society for Systemic Therapy and Family Therapy (i.e. DGSF: Deutsche Gesellschaft fu¨r Systemische Therapie und Familientherapie) and the Systemic Society (i.e. SG: Systemische Gesellschaft) to the Federal Scientific Advisory Board (i.e. WBP: Wissenschaftlicher Beirat Psychotherapie). Any form of psychotherapy which is not part of the recognized treatments need approval by the WBP, before the Board of Health Care Providers (i.e. GBA: Gemeinsamer Bundesausschuss) can even consider if they will start a second, independent rigorous assessment. To the dismay of many systemic therapists, this move was rejected by the WBP because of an insufficient data base. Subsequently, all forms of family therapy were banned (and still are) from reimbursement from the health insurance system of state and city officials (Beihilfe) and in the training regulations of psychiatrists, child and adolescent psychiatrists and doctors of psychosomatic medicine. Only behavior and psychodynamic therapies and psychoanalysis were considered a valid form of psychotherapy. In contrast, systemic therapy was not included. Schiepek, who had for some time been intrigued by the paradigm of synergetics, started to use this paradigm for psychotherapy process research. He now teaches at the University of Krems. After the cognitive turnaround of systemic therapy and the fashionable neutral stance required of therapists, many of the multigenerational aspects, emotional relatedness and meaning had been lost. In this context, Weber (1993) published a book on family constellations, developed by Bert Hellinger, which immediately became very popular. Hellinger, a former Catholic missionary to South Africa, who had been ousted from psychoanalytic training in Vienna because of his unorthodox views, received training in group therapy and Ericksonian therapy. He combined some ideas from Boszormenyi-Nagy with a particular form of family sculptures, and his own theoretical systems ‘‘orders of love’’. Family constellations address the inner representation of family systems, within a large group context, in a format which can be regarded as a form of healing rituals. Hellinger never worked with families and did not use systemic concepts. Nonetheless, it was called systemic and quickly turned into a mass movement, with many group therapists, humanistic therapists and people with a health care license started to conduct large group workshops across the country. The book was translated into many languages (Hellinger et al. 1998) and Gunthard Weber conducted workshops around the world. Like in the 1970s when Satir was criticized that her large group workshops on family sculpting were damaging to the reputation of family therapy, many systemic therapists were discontent with family constellation work. Eventually, the DGSF and SG published at joint statement in which they made clear that family constellations (as practiced by Hellinger) violated many professional standards. Today, the movement has subsided, and family constellations are regarded as a specific technique which can be used within a systems framework. Weber and Schweitzer are currently making an attempt to probe its effectiveness as a therapeutic tool in a study on treatment effects of family constellations. After 2000 For a couple of years in the late nineties, the IGST in Heidelberg was shaken by internal conflicts between the younger and older members of the group, and many of the former trainees were unpleasantly reminded of a painful divorce conflict between ‘‘parents’’. After a stalemate that lasted several years, which crippled the productivity and creativity of its members, the group split. Retzer soon founded his own institute, and the younger members

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Fischer, Gester, and Clement remained in the IGST. With support from Stierlin, Simon, Schmidt, Weber, the late Ru¨cker-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 fu¨r 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 master’s 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 author’s 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 Stierlin’s 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).

The Situation Today Family therapy approaches flourish in a few other university hospitals. In Freiburg, Wirsching continued to work with anorexia nervosa and psychosomatics, was involved in family systems medicine, and published an edited textbook on marital and family therapy. For the Working Group on Scientific Medicine (i.e. AWMF: Arbeitsgemeinschaft Wissenschaftliche Medizin), he also published the guidelines for couples and family therapy (Scheib and Wirsching 2004). In Go¨ttingen, Gu¨nther Reich, who had worked with Cierpka, continues to treat and study families with eating disorders. Friedebert Kro¨ger started to work at Aachen University Hospital and now directs a hospital in Schwa¨bisch Hall. Previously, he had worked with Werner Herzog in Heidelberg at the Psychosomatic Unit of the Department of Internal Medicine on family therapy with anorexia nervosa and the circumplex model. With Askan Hendrischke, and Susanne Altmeyer, Kro¨ger started to invite Susan McDaniel and published a number of books on family systems medicine (Kro¨ger et al. 2000). In the United States, a number of well-researched, manualized treatments such as Brief Strategic Family Therapy, Functional Family Therapy, Multidimensional Family Therapy (MDFT), Multisystemic Therapy (MST) have been used extensively. In an international, multi-centered study in Belgium, France, Netherlands and in Berlin/Germany, MDFT was implemented (Tossmann et al. 2010) and a number of groups started to use MST, especially in Switzerland (Fu¨rstenau and Rhiner 2010). The majority of those employed by youth protective services and drug counseling centers already have some training in systemic or other forms of therapy. At this point, these ‘‘trademark therapies’’ were not or are only partially superior to treatment as usual. Government authorities seem to be reluctant to pay for the expensive training and license. Also, as systemic therapy cannot legally be practiced in outpatient settings, the advance of any of these approaches is limited by the lack of recognition by the board of health insurers. Renaissance of therapy supported by video-feedback, which can be found in parentinfant therapy, is another more recent trend. This usually has a strong systemic foundation, as well as in approaches such as Marte meo which were originally developed for families with autistic children. However, it is now commonly used in a variety of settings such as child guidance centers (Bu¨nder et al. 2009).

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In recent years, a number of systemic therapists have started to teach at Universities of Applied Science where social workers and educational specialists are being trained. Simon and von Schlippe held a chair on Family Business at the University Witten-Herdecke, and Jochen Schweitzer has been working on the organizational theory of medical hospitals. In addition to teaching hypnosystemic therapy, Gunther Schmidt has worked in organizational consultation. He has also founded a flourishing private hospital, near Heidelberg systelios, which is based on his hypnosystemic approach.

Systemic Therapy in Austria and Switzerland In Austria, starting in the 1970s, Ludwig Reiter worked and taught at the renown Institute for Marriage and the Family in Vienna. In Switzerland, Gottlieb Guntern, who had spent a sabbatical at the Philadelphia Child Guidance Clinic, started to train family therapists in the late 1970s. In 1967, Duss-von-Werdt founded the Institute of Marriage and the Family in Zu¨rich, which was later headed by Jo¨rg Willi. Willi was a psychiatrist from Burgho¨lzli Hospital near Zurich who had developed his ecologically based marital therapy (Stierlin and Duss-von-Werdt 1985). Rosmarie Welter-Enderlin headed the highly influential Meilen Center. She had lived in the USA and trained with Haley and Patterson and maintained close contact to the American Academy of Family Therapy and to her friend Evan Imber-Black. She also promoted a humanistic-systemic couple therapy with a strong narrative foundation. Part of the success of her team in Meilen was a series of regularly held conferences to address specific aspects of systemic therapy. With Ulrike Borst as the new head, the center has now moved to Zurich and cooperates with the institute which Willi had founded. Guy Bodenmann at the University of Zurich has been researching and teaching behavioral couple therapy for the past few years. In Bern, Liechti and Zbinden provide comprehensive systemic training for therapists.

Journals and Publishers There are three German language journals on systemic therapy—Familiendynamik (Family Dynamics), founded by Stierlin and Duss-von-Werdt, Zeitschrift fu¨r systemische Therapie (Journal of Systemic Therapy) founded by Hargens, and Kontext (context), the journal of the DGSF. System Familie (family system), founded by Rosmarie Welter-Enderlin, was discontinued, but Psychotherapie im Dialog (dialogues on psychotherapy) discusses in every issue various topics from the perspective of different psychotherapy approaches, including systemic therapy. In 2005, Tom Levold, from the Psychoanalytic-systemic Training Institute in Cologne started systemmagazin, an online-journal of systemic therapy which is used by many therapists. Most large scientific publishing houses have series on systemic therapy. An influential publisher is Carl Auer Verlag in Heidelberg, originally founded by members of the IGST, which is now owned by Weber, Simon and Trenkle, which has a large number of titles on systemic therapy. Most scientific publishing houses such as Hogrefe, Jungermann, KlettCotta, Kohlhammer, Springer, Thieme, Vandenhoek and Ruprecht have a series of books on systemic therapy as well. Two textbooks on systemic therapy have been highly significant and have shaped the way systemic therapy is practiced and taught (Retzlaff 2012; von Schlippe and Schweitzer 2012). With so many fine books available in German, and a reluctance of many publishing houses to translate books because of the costs involved, many

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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 therapy—for 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 Trenkle’s ‘‘Kindertagung’’, a conference on hypnotherapy and systemic therapy with children held every 4 years in Heidelberg. Both DGSF and SG conduct annual conferences, with 300–1200 and 300–600 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 180–300 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 services—including psychotherapy—for 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 master’s degree, receive 600 h of courses in theory and 2,800 h of clinical practice. In addition, they will have about 8–12 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 master’s degree who work with children (i.e. educational specialists, etc.).

Training in Systemic Therapy Universities generally provide only very limited courses on systemic therapy, usually as part of a master degree program in clinical psychology. After the ‘‘Bologna reform’’ of university education, some of the Universities of Applied Sciences have started to offer programs in systemic social work, systemic supervision and the like, but these do not qualify participants for the practice of systemic therapy. While systemic therapy is highly popular with many practitioners, it has not entered into the university programs to a large extent. Most training programs in Germany have a strong lenience towards post-constructivist rather that pragmatic, empirically-based approaches of systems oriented therapy which means that systemic training and practice differs to a considerable extent from countries such as the USA. Training in systemic therapy is provided by about 150 private post-graduate institutes. After 3 years training in systemic therapy or in systemic counseling, participants receive a specialized certificate. Training consists of the following requirements: 300 h of theoretical teaching, 150 h of supervision, casework, and peer groups, 150 h of systemic self-experience, written presentation of cases and a colloquium or a written presentation. Training for specialization as a psychiatrist, child and adolescent psychiatrist or medical psychotherapist requires about 240 h of psychotherapy theory. Only recently, some state boards of medical examiners accept training in systemic therapy as valid hours. Kro¨ger, together with Herzog, founded a 100 h training program in family therapy for medical doctors, which is based in Heidelberg. In three out of 16 states of the Federal Republic of Germany, psychologists and child and adolescent psychologists with a state license can obtain a formal recognition as a ‘‘systemic therapist’’, which is currently not yet honored by health insurances. Although behavior therapists such as Revenstorf, Hahlweg, and Schindler worked and researched behavioral couple therapy, there is no formal training and no professional organizational group of behavioral family therapists in Germany. Following Richter, psychodynamic family therapists from Gießen, Go¨ttingen, Munich, and Heidelberg offer training in psychodynamic family therapy in five training centers.

Accreditation Standards for Training Programs in Family Therapy In order to get recognition, programs must be a member of one of the two systemic organization (DGSF or SG). Training must last a minimum of 3 years with at least two certified trainers/supervisors. The training must be continually evaluated in the process. Maintenance of standards of training is assessed at regular intervals by external evaluation.

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Specialized Qualification and Certification for Family/Systemic Therapy Practitioners A number of specialized qualifications are available, all of which require supervised case and peer group work as well as a varying amount of theoretical training: systemic therapy with children (150 h of theory), systemic coach (250 h of theory), systemic mediation (160 h of theory), systemic supervisor (250 h of theory). To qualify as a certified teacher of systemic therapy, systemic therapy with children, systemic supervision or systemic coaching, 5 years of practice and teaching and 5 years of experience and teaching are required. A number of institutes offer 2–3 year training programs in systemic therapy with couples, with 200 h of supervision and case work; however, no formal certificate is offered. The criteria seem somewhat outdated, and in contrast to Anglo-American training institutes, live supervision as well as observation of senior teachers doing case work is not nearly as established as in other countries.

Relationship of Family Versus Couple/Marital Therapy A 2 year long integrative psychoanalytic family therapy training exists, which includes a considerable amount of systemic and structural elements. Professional organizations of behavior therapists insist that all forms of pragmatic, evidence-based family therapy are not systemic therapy but a form of behavior therapy. However, behavioral training institutes hardly offer any training in any form of marital or family therapy. A large number of psychotherapists with a state license in behavior therapy—and a smaller number with a license in psychodynamic therapy—have received additional training at one of the systemic training institutes and will integrate both in their practical work (which is not legal). Some people believe that sooner or later, a form of general psychotherapy will be taught and practiced, which would include all forms of evidence-based psychotherapy, including systemic therapy, but this scenario seems to be rather far away.

Professional Organizations for Family/Systemic Therapists The German Society of Systemic and Family Therapy (DGSF, www.dgsf.org) is the largest organization, with about 4,500 individual members—psychologists, social workers, medical doctors; about 100 training centers are institutional members. Traditionally, the DGSF has an integrative-systemic orientation, which is reflected in the journal ‘‘Kontext’’ for members of the DGSF. About 25 special interest groups (such as ‘‘systemic work in psychiatric institutions’’) reflect the diversity of the members. The Systemic Society (i.e. SG: Systemische Gesellschaft, www.systemische-gesellschaft.de) has about 900 individual and 41 training centers as institutional members. Traditionally, it has a strong post-Milan constructivist orientation. Both DGSF and SG cooperate on many levels. The Federal Association Psychoanalytical Family Therapy (i.e. BVVP: Bundesverband Psychoanalytische Familientherapie, www.bvppf.de) has about 240 individual members and five training centers as institutional members. ¨ AS; There is an Austrian Society for Systemic Therapy and Research (i.e. O www.oeas.at) and a Swiss Union for Systemic Therapy and Counseling (i.e. Systemis, www.systemis.ch).

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Future Directions for Family Therapy Practice, Training, and Recognition in Germany Future developments will depend on the larger sociopolitical influences. Generally, change in the health care and the university system is exceedingly slow. In the 5 years since systemic therapy has been recognized as an evidence-based treatment, the board of health care providers has contemplated if they will start with an independent evaluation process. Evaluation of systemic therapy with adults will take 3–5 years; only afterwards, a formal evaluation of systemic therapy with children and adolescents could commence, which would take an additional 3–5 years. Within the next 6–10 years, universities might start a new type of training in both clinical psychology and psychotherapy on a model similar to training in medicine, which would lead directly towards a state license. This would be followed by 2–3 years of special psychotherapy training offered at private and state schools of professional psychotherapy. Possibly, this training could be based on some sort of an integrative psychotherapy model. Another scenario is that, in case of a rapid decline of the social and health care system in the aftermath of the current financial crises, psychotherapy might be dropped to a large extent from the list of treatments paid for by public health insurance, which would be detrimental to the practice and training of all forms of psychotherapy.

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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