Brief Treatment and Crisis Intervention Advance Access originally published online on December 11, 2008
Brief Treatment and Crisis Intervention 2008 8(4):352-357; doi:10.1093/brief-treatment/mhn022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Public Subsidized Assistance for Psychological Counseling in the Danish Public National Health Insurance Service
From the Department of Psychology, University of Aarhus
Contact author: Professor Ask Elklit, Clinical Psychologist, Jens Christian Skous Vej 4, DK-8000 Aarhus C, Denmark. E-mail: aske{at}psy.au.dk.
In 1992, the Danish governmental National Health Insurance Service came to a provisional agreement (Sygesikringsoverenskomsten) with the Danish Association of Psychologists. The agreement was to financially support a publicly subsidized system for people who have experienced a traumatizing or life-threatening event to be able to receive psychological counseling. The agreement specifies a number of specific incidents that would constitute as qualifying for receiving the subsidized counseling. The Danish system is unique in terms of acknowledging the need for therapy following a traumatic or life-threatening event and financially supporting anyone who meets the criteria. The first evaluation of the agreement investigated the outcome of the counseling services. The evaluation suggested some adjustments and ultimately concluded that the project was a success, which subsequently led to the agreement being made permanent. In April, 2008, the agreement was expanded with the addition of further qualifying categories for which individuals could receive subsidized counseling.
KEY WORDS: subsidized crisis counseling, trauma, health insurance, victims, Denmark
Denmark discovered a renewed interest in the area of trauma and crisis, following the fire onboard the "Scandinavian Star" en route from Norway to Denmark on April 7, 1990, in which 159 Scandinavians died. Many professionals criticized the existing emergency preparedness and crisis management system in Denmark for being both insufficient and for not offering the survivors and their relatives the support and counseling needed in a timely manner. The Danish Government decided that each county should create a set of guidelines for psychosocial services after disasters. The guidelines were proposed so that each local area of the country was prepared to handle an emergency effectively and in a timely manner.
In 1992, an agreement was reached between the public National Health Service in Denmark and the Danish Association of Psychologists to commence a two and a half year pilot project to partially finance the cost of psychological treatment for people in need of counseling due to certain life events or incidents. The idea behind the project was to see if the service could reduce the amount of paid sick leave taken, as well as improve the overall life quality among people struck by a crisis. The amount of paid sick leave Danes are able to take during a year is quite high (approximately U.S. $ 22.000) and, therefore, costly for Danish employers.
 |
The Agreement and the Criteria for Receiving Subsidized Therapy in Denmark |
|---|
 TOP The Agreement and the... Historical Development of the...Implications of the Subsidized...References |
|---|
The agreement originally stated that clients qualifying for the subsidy could receive a maximum of 12 sessions with a private practice psychologist. It was agreed that clients would be responsible for paying only 30% of the fee, whereas the rest would be subsidized by the state. The agreement has since changed and clients now have to pay 40% of the total fee (Ministeriet for Sundhed og Forebyggelse, 2008).
To be eligible to offer psychological counseling services to clients with subsidies, private practice psychologists must apply for a license under the agreement (ydernummer), which guarantees a certain number of psychologists distributed across the country in every region. The private practice psychologists must have obtained authorization and must be available for a minimum of 22 hr a week and cannot be employed elsewhere for more than 15 hr per week. By March, 2006, there were 633 licensed psychologists serving a population of 5 million inhabitants (Elklit et al., 2007).
To qualify for the subsidy, the individual must have experienced a triggering event causing symptoms or reactions in the individual that may be relieved through psychological counseling. In addition, the individual must obtain a written referral from his or her primary physician (general practitioner) within 6 months after the triggering event. However, exemptions are granted regarding the time frame in cases where the individual was a victim of incest or any other sexual assault before the age of 18. The triggering event must place the victim in one of the following categories:
- Victims of robbery, violence, or rape.
- Victims of traffic accidents and other accidents.
- Relatives of seriously mentally ill individuals.
- Individuals or relatives of patients suffering from a seriously disabling disease or illness.
- Bereaved.
- Individuals having attempted suicide.
- Women having gone through an abortion past week 12 of their pregnancy.
- Victims of incest or victims of any other sexual assault prior to the age of 18.
- Victims of traffic accidents and other accidents.
Victims of Robbery, Violence, or Rape
The individual qualifies if he or she is the primary victim. Secondary victims, such as witnesses or individuals attempting to help the primary victim, may qualify if they have been in real danger or have been threatened during the incident. Violence in this category includes both psychological and physical violence. A domestic violence incident would qualify, but if the domestic violence has been a pattern in the family for more than 1 year it will not qualify. Rape, attempted rape, and other sexual assaults all qualify in this category. There is no requirement that the incident was reported to the police.
Victims of Traffic Accidents and Other Accidents
The individual qualifies in this category if he or she is directly or indirectly involved in an accident, regardless of who caused the accident. Traffic is to be understood broadly, covering cars, bicycles, pedestrians, and smaller aircrafts. The term "other accidents" covers any other accidents besides traffic accidents big enough to cause an individual to need psychological counseling.
Relatives of Seriously Mentally Ill Individuals and Relatives of Patients Suffering from a Seriously Disabling Disease or Illness
In these two categories, the term "relatives" covers the closest relatives of the individual such as spouse, siblings, and children. In most cases, stepparents and half siblings are covered as well. This means that there may be cases in which both biological parents and stepparents to a child may receive subsidized counseling. In-laws and more distant relatives are usually not covered, but in cases where they are the only family members involved, they may be covered.
The term "seriously mentally ill" does not refer to specific diagnosis. The determining factors are whether the specific consequences of the mental illness influence the behavior and interpersonal relations of the individual in a serious manner. As a result, the criteria must be evaluated individually in each case to determine whether the relatives of the individual qualify.
Individuals Suffering from a Seriously Disabling Disease or Illness
A disabling disease or illness does not only include cases where the individual is immediately and seriously disabled, it also includes conditions where the diagnosis itself can cause the individual to experience a crisis. This includes diagnosis like cancer, AIDS, thrombus, arthritis of the joints, sclerosis, and muscular dystrophy. Usually, the time when the individual is diagnosed is when the time frame for the referral is considered. If an individual has been diagnosed in the past, and he or she has already received a subsidy for counseling, he or she can still qualify for the subsidy for more treatment if either the diagnosis is a new diagnosis (two separate illnesses) or if the illness progresses in severity or location (e.g., if a cancer spreads to other organs). If the illness progresses in severity but is as expected (e.g., a cancer patient reaches a terminal stage) the individual does not qualify for the subsidy.
Relatives Suffering a Loss
The term "relatives" covers the same criteria as mentioned above. In this category, parents of a stillborn child also qualify for the subsidy, as well as parents suffering an unwanted abortion past week 19 of the pregnancy.
Women Having Gone through an Abortion Past Week 12 of Their Pregnancy
The counseling service can be offered prior to the actual procedure, as long as the permission for the procedure has been granted.
Victims of Incest or Victims of Any Other Sexual Assault Prior to the Age of 18
Individuals pertaining to this category do not have to adhere to the time frame for referrals. A referral can be given for psychological counseling throughout a lifetime as long as the incident happened before the age of 18.
|
Historical Development of the Program |
|---|
|
TOPThe Agreement and the...Historical Development of the...Implications of the Subsidized...References |
|---|
The project started in July, 1992, and was evaluated 2 years later (Mehlbye & Laurents, 1994). The goal of the evaluation was to gather information about the private practice psychologists, physicians, and clients, as well as examine how and how much the clients benefited from the counseling services. The evaluation was based on questionnaires sent to the psychologists, physicians, and clients. The questionnaires were sent to the three groups at the beginning of the counseling treatment and at the end of the counseling treatment. The final analysis included 240 cases.
About half of the clients utilizing the psychological services were referred after suffering a loss. About two-thirds were referred because of an acute incident involving rape, violence, or death and one-third due to less acute events such as clients diagnosed with a seriously disabling disease and relatives of such clients (Mehlbye & Laurents, 1994). Of all clients receiving treatment, only about 9% continued treatment through all 12 sessions granted. In all, 15% terminated treatment prematurely, of which half stated the reason as being "not benefiting enough from treatment." Of the clients continuing treatment through all 12 sessions granted, about half stated that the offer was too limited and that they felt additional sessions would have been beneficial. These clients were primarily referred due to more chronic illnesses or diseases such as cancer (Mehlbye & Laurents, 1994).
In total, 90% of participating clients receiving treatment stated that they had benefited greatly or somewhat from the counseling services and 10% stated that they had benefited only a little from the treatment (Mehlbye & Laurents, 1994). The clients reported that they felt less depressed, had fewer sleep related problems, were better able to focus and make decisions, and had increased feelings of self-worth. About half of the clients also reported that they had stopped their use of sedatives. The psychologists stated that about half of the clients seemed calm and well balanced and that only a few (9%) displayed anxiety, whereas about one-fifth continued to appear depressed. The referring physicians also believed that the majority of their clients felt better mentally after receiving psychological counseling (Mehlbye & Laurents, 1994).
Whether the overall positive effects of the psychological counseling were a result only of the counseling services is difficult to assess. The evaluation did not include a control group; hence, the actual effect of the counseling services could have been influenced by other factors. The importance of the evaluation was to assess how much the individual client benefited from treatment given the client's circumstances before and after treatment (Mehlbye & Laurents, 1994). However, the project has since become permanent, is still receiving funding from the government, and the agreement has been expanded. The most recent numbers available (Elklit et al., 2007) show that in 2006, 42,575 clients saw a psychologist as a result of the subsidy agreement. The overall cost was approximately 158 million Danish kroner (U.S. $32 million). Of this amount, the fees paid by the clients constituted about 63 million Danish kroner (U.S. $13 million or 40%). The overall subsidy paid by the state in 2006 was about 95 million Danish kroner (U.S. $19 million).
In April, 2008, the agreement was expanded with 20 million Danish kroner (U.S. $4 million) being made available annually until 2011. This government funding is to be used to offer psychological counseling services to individuals between 18 and 37 years of age suffering from mild to moderate depression regardless of cause. The referring physicians base their referrals on a simple psychometric checklist. Clients are allowed a maximum of 12 sessions and are responsible for covering 40% of the total fee. The expansion of the agreement means that the number of licensed psychologists under the agreement has now been increased to a total of 801 psychologists.
The agreement has had an impact on the development of similar arrangements based on privates insurances. A leading national ambulance and car emergency company (Falck) offers four free sessions with a psychologist following an accident available within 12 hr, as part of a car insurance package. Both the driver and the passenger are covered (http://www.falck.dk/). Several other insurance companies (e.g., http://www.tryg.dk/) offer 10 free sessions with a psychologist following a number of other triggering events as part of their insurance packages. A very large number of private companies and work places offer free psychological counseling to employees following robbery, assault, accidents and, increasingly, also in case of divorce, substance/alcohol abuse, stress, and harassment.
At the present time, there are few data available regarding the use of psychological counseling following traumatic events in these private insurance companies. Falck released an estimate in 2005, stating that they offer a psychological counseling service for approximately 10,000 events yearly, a large part of which is related to major traffic incidents (Elklit et al., 2007). Most of the companies are reluctant to release this kind of information to the public and only one outcome study has been carried out to shed light on the extent of the use and the effect of these services from a national public health perspective (Elklit, 2000). However, in recent years, there has been a growing demand from the public and increasing expectations regarding the availability of these services, and private services have expanded to a degree where most of the working force will receive psychological counseling after a serious incident.
|
Implications of the Subsidized Counseling Agreement in Denmark |
|---|
|
TOPThe Agreement and the...Historical Development of the...Implications of the Subsidized...References |
|---|
Before the agreement to offer subsidized counseling in Denmark was established, there were two options for individuals in need of crisis counseling. They could see a private psychiatrist or psychologist. Clients would pay for the treatment in full, which is quite costly, and often there would be a very long waiting time even for a first session. They might also be referred to the public psychiatric services, where most psychiatrists had little or no experience with crisis work in a nonpsychiatric population, which many considered stigmatizing. Almost no client focused associations or self-help groups were established in the area of psychotraumatology, and most specialized counseling centers were focused on working with children and adolescents or first time single mothers.
Because the agreement was made permanent, the media in Denmark has been increasingly focused on what the public can and should expect from the public system in terms of emergency preparedness, crisis management, and access to counseling and crisis intervention. A small incident can illustrate this: a mother whose daughter was stabbed to death complained to a newspaper that she had to wait for 17 hr before she could see a psychologist. The following day, the administrative director of the county expressed his regrets on the front page of the newspaper and said that the efficiency of the public services would be improved. The growing demand for services in the private and the public sectors have beyond doubt greatly benefited many people. As a result of the increasing media coverage given to the field of psychotraumatology in Denmark, in part because of this unique approach to public subsidized counseling, several other vulnerable groups in the field of mental health have received more attention in latter years. Hence, the Danish military has had a renewed focus on the consequences of deployment, both for soldiers and their families. Several community agencies within the field of psychotraumatology have also recently received permanent funding from the state government, to offer more specialized and comprehensive trauma services for certain populations, for example, regional rape crisis centers and a center for victims of incest.
Overall, the implications of this new approach to public subsidized counseling in Denmark seem to be that more people have received more and better services, and the results so far show that the agreement has had a positive effect on the mental health of people who have experienced a traumatizing or life-threatening event.
|
Acknowledgments |
|---|
Conflict of Interest: None declared.
|
References |
|---|
|
TOPThe Agreement and the...Historical Development of the...Implications of the Subsidized...References |
|---|
-
Elklit A. Psykologisk traumebehandling—En effekt-undersøgelse (2000) [Psychological trauma treatment—An effect study]. Copenhagen, Denmark: Dansk Krise-og Katastrofepsykologisk Selskab.
Elklit A, Isidor S, Konnerup A, Kristensen TE, Lyngby M, Obaidi M. Psykologisk Krisehjælp—Ydelser, Ordninger og Behov (2007) [Psychological crisis intervention—Services, sgreements, and Needs]. Copenhagen, Denmark: Dansk Krise-og Katastrofepsykologisk Selskab.
Mehlbye J, Laurents CB. Psykologhjælp med Sygesikringstilskud. En Evaluering (1994) [Subsidized Psychological Counseling. An Evaluation]. Copenhagen, Denmark: AKF Forlaget.
Ministeriet for Sundhed og Forebyggelse. Aftale om Satspuljen På Sundhedsområdet 2008–2011 (2008) [Agreement of Funds in the Area of Public Health for 2008–2011]. Retrieved from http://www.sum.dk/sum/site.aspx?p=2564&t=ForsideVisartikel&Articleid=4701.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||