There has been a tradition of holistic thinking in Germany since the epoch of so-called romantic medicine at the beginning of the 19th century (H. Heinroth,
G. carus). This was speculative and mystical, and it focused on the unity of body and mind. There was an interest in the “dark side of the soul”, the unconscious and the dreams, which was also reflected by philosophers like A. Schopenhauer, who had worked on the concept of unconsciousness. A strongly scientific medicine developed in the middle of the century, which is tied to the names of W. Griesinger, and R. Virchow, who were also interested in the social aspects of medicine. This discourse about bio-, psycho-, social-medicine never stopped. Despite the rapid development of scientific medicine, a philosophically influenced debate took place at the end of the 19th century. It focused on questions about the relationship between body and mind and on matter and spirit and extended to the beginning of the 20th century [
3]. In this time the change from philosophy and psychology (W. Wundt, 1896) to medicine was very close. It is interesting that philosophical schools of phenomenology (E. Husserl), existence philosophy, and hermeneutics (M. Heidegger) had described essentials of the human being as “anthropology”. These philosophers and physicians were familiar with their thoughts. Like the psychiatrist K. Jaspers or the internist V.v. Weizsäcker, they had a strong influence on psychosomatic medicine. This was the climate in which psychosomatic medicine in Germany developed as a basic anthropological orientation in medicine (medicine focused on the individual as a whole and his “being”), as well as an interdisciplinary scientific approach to the study of man and finally a reflection on the applied methods for describing and studying an object and taking into account their limitations [
4]. In those days, scientific medicine and knowledge about diseases developed extensively, but L.v. Krehl (1907) was able to state: “We do not treat diseases, but sick people”. Psychosomatic thinking appeared to promote this integration of the human being and his environment.
At the beginning of the last century, German physicians observed an increase in neurotic diseases. War neuroses and functional disorders without organic findings were increasingly seen during World War I (1914–1916). The lack of therapeutic options in the entire field of internal and psychiatric medicine was a reason for developing psychoanalytic oriented psychotherapy and the origins of psychosomatic medicine: Between the two world wars, approaches were made by leading internists V.v. Weizsäcker, G.v. Bergmann, K. Hansen, and coworkers. Moreover, the experience of the national socialist regime and World War II enabled internists like A. Jores to become more familiar with psychosomatic aspects, which they had experienced by themselves or observed in others during that dreadful time. Especially at the internal medicine conference in Wiesbaden in 1949 and by influential internists (T.v. Uexküll, A. Jores et al.), the further institutional development of psychosomatic medicine at universities and in the German health care system was supported. But psychosomatic medicine and its integration in the German academic world and in the area of health care had, compared to other countries, a specific historical, sociological, health policymaking, and medical dimension, which allowed this development and influences it until this day [
2]:
Historical dimensions
After World War I psychoanalysts established an institute for advanced psychoanalytic training in Berlin and assembled several representatives of the inner circle around S. Freud. The first psychotherapeutic meetings took place under the presidency of C.G. Jung in the 1920íes and brought together all internists, psychiatrists, and therapeutic physicians interested in psychoanalytically oriented psychotherapy. In this time, psychoanalysts and internists involved in psychosomatics (F.Alexander, E. Wittkower) and the founder of GP-discussion-groups (E. Balint) got their training in internal medicine and psychoanalysis in Berlin. Between 1927 and 1930, psychoanalytic clinics were founded by E. Simmel in Tegel and by G. Groddeck in Baden Baden, and a psychosomatic inpatient unit was established in the medical department at the University of Heidelberg by V.v. Weizsäcker. After 1933, the National Socialists (Nazis) fought against psychoanalytic therapy. Most psychoanalysts emigrated and psychoanalytical oriented psychiatrists closed their offices (E. Kretschmer). Only a small group under the protection of a high-ranking administrator (M.H.Göhring) partly identified with the Nazi regime and could continue working in a separate group with a broad range of psychotherapeutic methods (autogenic training by I.H. Schultz, neo psychoanalysis by H. Schultz-Henke). After World War II, two separate psychoanalytic groups (the therapists who stayed on and the emigrants) fought against each other. The emigrants were in close contact with the ideas of the international psychoanalytic society and became official members. They criticized the psychotherapeutic group that remained in Germany, which may have been influenced by Nazi ideology according to their new psychotherapeutic theories and practices. In addition to these groups, psychiatrists (E.Kretschmer) and other clinicians supported the development of psychotherapy in Germany by founding special training sessions (Lindau-psychotherapeutic-week) or scientific journals (Psychotherapy, Psychosomatics and Medical Psychology, 1948). Also, other individuals involved in theory (W. Reich) and the practice of body therapy (E. Gindler, M. Fuchs) have influenced the evolution of German psychosomatic medicine, as well as new psychotherapeutic methods of group therapy, family therapy, and gestalt therapy.
Important to the development of psychosomatic medicine was the physician A. Mitscherlich, who was persecuted and imprisoned by the Nazis and later became (1941) V.v. Weizsäcker’s assistant. He documented and observed the Nuremberg Trials to the extent that they concerned Nazi physicians. When he tried to found an independent psychosomatic institution, he obtained support from the internists, but the head of the psychiatric clinic and other members of the faculty cooperated in the old spirit of the Nazi era and refused a separate department. As a trainee of the Psychoanalytic Institute in London and with funding by the Rockefeller foundation from the USA, he was able to convince German politicians and built his own psychosomatic clinic at the University of Heidelberg.
A similar course took place until 1965 under the protection of the heads of internal medicine departments at the universities of Freiburg, Munich, Hamburg, and Giessen. A number of outpatient and inpatient clinics were set up outside the universities. All of these facilities became nuclei of a development of independent psychosomatic-psychotherapeutic departments outside psychiatric and psychological institutions at many universities (see below).
Medical
In 1967, psychotherapy was included in the German health care system. All patients could get up to 50 sessions of psychotherapy, much more than in other western countries at that time. This was the activity of scientists who could demonstrate the effectiveness of psychotherapeutic treatment [
6], but also was a concerted effort by very active groups such as the Physicians society of Psychotherapy, both psychoanalytic societies, the General Practitioner organization, as well as various internists and psychiatrists.
With support of internists (T. v. Uexküll) and psychotherapists (H.E. Richter), psychosomatic medicine was integrated, like in some other Western countries, into medical training at the universities (1970, see below). Experienced and well-known scientists of psychosomatic internal medicine or psychotherapy and psychosomatics became full professors at the universities and built their own independent departments (five as part of medical clinics). To date, 25 departments at 34 medical faculties in Germany have been established, with 22 full professors. The heads of psychosomatic clinics or departments have, as a group, become very influential in Germany and were engaged in the inauguration of both societies.
In 1974, the
German College of Psychosomatic Medicine (DKPM) was founded by internists and psychotherapists (T.v. Uexküll, P. Hahn, A.E. Meyer, W. Schueffel et al.) in close relation to the thoughts and activities of the International College of Psychosomatic Medicine [
7] and the European Conference of Psychosomatic Research (ECPR). The focus of these societies was on psychological aspects of physical symptoms and disorders, and the conferences were very psychotherapeutically oriented with a focus towards psychoanalytic theory. This college (with about 400 members today) was and is an interdisciplinary, integrative scientific professional association with activities in the whole field of medicine for doctors, psychologists, and other professions (e.g. art therapists). It attracted excellent scientists other than those in clinical medicine, psychophysiology (J. Fahrenberg), medical sociology (J. Siegrist), or medical psychology (D. Beckmann), who became members and broadened the scope of this society. In this time close co-operation; a main aim of DKPM; the establishment of many psychosomatic societies of other specialties (e.g. General practitioners, gynecologists, dermatologists, orthopedists) was seen as were psychological societies (medical and clinical psychology) following the concept of (holistic) integrated psychosomatic care in all fields of medicine. In addition to the new development at the universities in the training of all medical students, later it ran and promoted post-graduate research-based training and advancement in all areas of psychosomatic medicine, supported by the Swiss-based Carus Foundation.
A main focus of DKPM scientists was clinical research involving patients of respective hospitals with psychosomatic institutions. Additionally three psychosomatic basic funding fields (SFB’s) of the German Research Council were inaugurated together with other medical disciplines: psychological measurement/psychiatry and psychosomatics (SFB32, Giessen), pulmonary diseases/endocrinology (SFB34, Hamburg) and epidemiology/psychiatry and psychosomatics (SFB116, Mannheim). Later, research exchange formed strong ties to other European, American, and Asian societies involved in the field of psychosomatic medicine. An early exchange of scientists and discussions took place with the American Psychosomatic Society in the 1970íes (H. Weiner, R. Adler, F. Lamprecht). Later, DKPM members were involved in the European C/L study and the following co-operative studies (F. Huyse, U. Malt, T. Herzog, F. Creed). They founded the European Network on Psychosomatic Medicine (2005) and become a member of the International Society of Behavioral Medicine (2008, K. Orth-Gomér, N. Schneiderman). Especially to Japan, there has been a long history of communication with members of the Japanese Society of Internal Psychosomatic Medicine. Our first contacts were with Y. Ikemi, Y. Ago, and H. Suematsu in the 1970ies and 80ies of the last century [
8], and now through the ICPM with C. Kubo, Y. Nakai, and M. Murakami. This culminated in the signing of an agreement about Friendship and Cooperation between JSIPM and DKPM in November 2011. Since that time there have been regular exchanges and meetings during national conferences in both countries.
A further and most important step has been with the introduction of a specialty of Psychotherapeutic Medicine (this was already installed in the former German Democratic Republic) at the German Physicians Congress in 1992 (P. Janssen. S. O. Hoffmann, H. Schepank). Especially, heads of the departments of psychosomatic medicine committed themselves to establish psychosomatic medicine as an independent specialty in medicine. They were convinced that only a specialization allows intensive training in psychotherapy and psychosomatic medicine. In 1992, the German Society for Psychosomatic Medicine and Psychotherapy was founded. With the unification of this society in 2005 with the Physicians Society of Psychotherapy (AÄGP) - the society for physicians of all specialties trained in psychotherapy, which was founded in 1927 - they changed its name to the Society of Psychosomatic Medicine and Medical Psychotherapy (DGPM). It focused on applying psychotherapeutic and psychosomatic methods at different levels of medicine and in the field of psychosomatic medicine. The society has about 1400 members, mostly practitioners in private practice. The main interest of this society at the beginning was to integrate practical questions of organization, training, and finances of German physicians in the inpatient and outpatient setting. They also wanted influence standards of regular training for this specialty and all other physicians trained in psychotherapy or psychosomatic basic care. This led to co-operation, but later on also to competition with physicians of other specialties, especially with psychiatrists.
In this time and later, the German Society of Psychiatry (DGPPN) was not in favor of the founding of DGPM (and renamed itself later with the adjunct psychosomatic), because at that time in psychiatric organizations, departments, and C/L psychiatry sections there was fruitful co-operation, but also competition in theoretical discussions and practice. The institutional independence of psychosomatic medicine in Germany is largely due to German psychiatry often resisting the integration of psychotherapy as a core method. Some groups gave support for psychotherapeutic methods. Hence, psychosomatic medicine developed independently as an institutional and academic basis for psychotherapy in medicine and later for integrated care models [
1]. The independence of the society makes it possible to commit itself to the specific interests of psychosomatic medicine in the German health care system.
Common and different scopes of both psychosomatic societies
Common activities in the physician organizations and universities in the last 15 years have become very important, including health care, research, physicians/students training, and common conferences. Many professor positions were initiated additionally (e.g. for psychotherapeutic research, psychosomatic genetics, psychosomatic dermatology, etc.), and there was discussion about common and different points of view in both societies to strengthen the power of psychotherapeutic and psychosomatic medicine in Germany.
1.
Basic needs and activities that focus on all physician groups working in the medical field could be understood by a holistic psychosomatic perspective. The physician’s way of acting on patient satisfaction and on treatment outcome consists of three elements: (1) hands on diagnostic examination (“be-handeln” in German), (2) carry through or organize different additional examinations through colleagues and (3) to communicate and understand patient needs (“be-nennen”- give them a name) and explain diagnostic and therapeutic activities. Physicians in specialties like internal medicine are involved in basic internal care. Interactions between physician and patient are part of their treatment. The special knowledge, experiences, and skills in internal medicine, as well as the communication and behavior of a physician, influence this treatment effect. Thus, societies of internal medicine, psychosomatic internal medicine (like JSPIM), and integrative internal and other specialties (like DKPM) and partly DGPM (which has developed a special training (P. Janssen) are involved in basic care and psychosomatic basic care. Psychotherapists implement additionally verbal, suggestive, or hypnotic therapeutic techniques, which is in depression on a group level not more effective than psychopharmacology. The mean effect size (ES) of psychotherapy compared to no treatment (or treatment as usual) was shown in 15 controlled studies of different diseases to have an ES of .80, but placebo compared to no treatment had an ES of .42, in psycho-diagnostic measurements [
9]. Placebo research has taught us that behavior, intake of placebo drugs, or bodily handling have a treatment effect in different diseases. These methods are used by GP’s and other specialties less trained in psychotherapeutic medicine. The goal of “integration of psychosomatic medicine in all clinical fields” is presumably more reachable with a specialty integrated society (e.g. JSIPM) or an integrative society like DKPM with psychosomatic active physicians e.g. GPs, gynecologists, and orthopedists. In-patient settings are common in Germany and show clear advantages in individual stages of psychosomatic or psychological diseases, e.g. anorexia nervosa [
10].
2.
Competition and cooperation within the medical field: A psychosomatic specialist society like DGPM is compared to others (surgery, internal medicine) in inpatient and outpatient health care and according to influence and power on the same level. Thus, the specialist society may be more effective in collecting institutional and health care advantages. A specialty in psychotherapeutic medicine (e.g. DGPM) will focus on patients, where psychotherapy can be successfully applied. It may focus on diseases, which will be treated effectively by psychotherapeutic and psychosomatic methods. This society can also give support for the development of psychosomatic basic care in the different medical specialties, if these like to cooperate. This is in contrast to psychiatric societies in the medical field, which focus much more on psychopharmacological treatments for severe psychiatric diseases or short psychotherapeutic interventions, in special cases [
11].
3.
Professional activity: a specialist society like DGPM is focused on physicians as regular members. An interdisciplinary society like DKPM tries to integrate all scientists and clinicians working in the field of medicine: Professionals like psychologists, sociologists, biochemists, physiologists, nurses, and physiotherapists are members and seem to be of the same “rank”.
4.
Teaching activities: The teaching of psychosomatic diagnostics and psychotherapeutic methods to students, trainees in their own specialties, and physicians of other specialties is an important task. Both societies were very successful in recent years at the universities, but DGPM worked more in a structural and professional way for the training of physicians and practitioners in an own practice. This training needs cooperation, if the borders between medical fields are unclear and the psychotherapeutic specialist society is interested in working in the fields of specialties, which were involved in the same matter.
5.
Research: In its national history Germany developed a holistic psychosomatic and strong psychotherapeutic tradition, which led the way to a psychosomatic/psychotherapeutic specialty. It depends in both societies on experience, wisdom and skills, and the ability to remain or to extend this position and to be successful in competition with other groups working in the field. Due to tradition, clinical activities and competition among psychosomatic scientists in Germany tend to focus on clinically interesting topics relevant to psychotherapeutic activity in some important diseases (see below). DKPM had a broader scope, e.g. in important or other diseases not close to psychotherapeutic activities, in mechanism or public health issues to extend scientific activities in clinical fields, which to date had stimulated only limited interest.
6.
International communication and cooperation is needed: a) Many clinicians and scientists from abroad are uncomfortable with the German history and psychosomatic structure in the health care system. If they compare it with their own situation, they are sometimes interested in copying it (but this is not easy, because there are mostly historical and economic differences) or they have completely other ideas and priorities in working in the psychosomatic field in their respective countries, e.g. the International Society of Behavioral Medicine (ISBM) is mainly influenced by psychologists and the Academy of Psychosomatic Medicine (APM), European Association for Consultation/Liaison Psychiatry and Psychosomatics (EACLPP) and its follower European Association of Psychosomatic Medicine (EAPM) by consultation liaison psychiatrists. It takes both information, communication, and discussion of an integrative international based German society like DKPM to communicate freely with all international groups involved in psychosomatic medicine. The combination of psychosomatic medicine and psychotherapy in the DGPM can cooperate also with other psychotherapeutic international organizations. The Society of Psychotherapeutic Research (SPR) and the International Federation of Psychotherapy (IFP) have different scopes than psychosomatic/behavioral international societies. There is an historical development in Germany to combine psychosomatics and psychotherapeutic medicine, so it is a new task to convince international partners involved in psychosomatic medicine or in psychotherapy to cooperate.
Psychosomatic medicine in Germany in the present structures represents a comprehensive field [
2] as well as a specialized medical discipline [
1]. The two societies, DKPM and DGPM, and their co-operative partners are engaged in activities for patients in health care and for physicians and other care givers in research, training, and national conferences. An English textbook representing psychosomatic medicine in Germany is missing, but a summary of German psychosomatic knowledge has been published [
12].