German mental health system has entered a 'dead loop' // Deutsches Versorgungssystem für psychische Gesundheit in einem „Teufelskreis".
- Singularity Academy
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Updated: 10 hours ago
Private psychosomatic clinics owner Prof. Dr. Ying Zhang argues that rising demand, contracting public capacity, two-tier insurance, and an exhausted workforce are now reinforcing one another — and proposes five structural reforms.
ZURICH / TODTMOOS/FULDA, 26 May 2026 — Germany’s mental health care system has entered a self-reinforcing structural crisis — a "dead loop" in which patient demand, clinical capacity, insurance design, and workforce burnout are pulling the entire sector downward together. That is the central argument of a new perspective essay published today in Singularity Academy Frontier Review(ISSN 2813-3641; Article SAFR 20260526). The piece is unusual for the field: its author, Prof. Dr. Ying Zhang, is not an academic observer of the system but its operator. She is the owner of the Verus Care Group, a Swiss-invested mental health group with two private psychosomatic clinics in Germany, and the president of Singularity Academy in Switzerland.
Numbers that point in one direction
Zhang anchors the argument in the most recent federal data. The Robert Koch Institute’s panel-based estimate of depressive symptoms in the adult population rose from 7.5 per cent in 2020 to 14.8 per cent in 2023 — essentially doubling in three years. The DAK Psychreport 2024 records mental-illness-related sick days at a new historical maximum. Average waiting times for an initial outpatient psychotherapy session now reach twenty to twenty-four weeks in rural regions, according to the Bundespsychotherapeutenkammer.
Supply is moving in the opposite direction. The number of statutory psychiatric and psychosomatic hospital beds has been falling since the early 2010s, and the European Mental Health Roadmap describes a continent-wide shortfall of roughly 1.2 million health workers, with burnout among professionals themselves accelerating attrition.
“Demand is rising. Supply is at best holding steady. The system rations mental health care more strictly than it rations somatic care, and the rationing falls disproportionately on the patients who can least afford to wait.”
— Prof. Dr. Ying Zhang, Singularity Academy Frontier Review (2026)
Access rationed by insurance tier
Roughly 89 per cent of Germans hold statutory health insurance (GKV); about 11 per cent hold private cover (PKV). For most somatic conditions the split is an inconvenience. For mental health, Zhang writes, it is a "chasm" — privately insured patients report substantially shorter waiting times, and statutorily insured patients are far more likely to face excessive waits. Private clinics willing to expand capacity cannot do so sustainably at statutory rates, which Zhang argues do not cover what good care actually costs.
A cultural diagnosis, with help from outside the clinic
The essay draws on Byung-Chul Han’s "Burnout Society" and on Alain Ehrenberg’s "Weariness of the Self" to argue that German patients increasingly present not with conflicts but with insufficiency — the fatigue of not becoming the version of oneself that one had imagined. A new section in the May 2026 revision incorporates commentary from JK, a senior IT professional with decades of experience inside German private and public clinics, who describes a measurable generational shift in resilience and stress tolerance among employees born after 1995. Zhang treats his observation as a serious empirical claim and links it to the Trendstudie Jugend in Deutschland 2025 and the 19th Shell Jugendstudie, which together document elevated stress, exhaustion, and demand for psychological support among younger Germans.
A fiscal question, not only a clinical one
Zhang situates the clinical analysis inside Germany’s tightening fiscal position. The 2025 reform of the debt brake (Schuldenbremse) and the 500-billion-euro extra-budgetary fund were, she argues, partly an admission that the existing rule could no longer finance the obligations the welfare state has accumulated. Estimates from the Verband Forschender Arzneimittelhersteller place the macro-economic cost of sickness absence at around forty billion euros a year — close to one per cent of annual GDP — with mental-health diagnoses now the second most cited cause of sick days after respiratory infections.
“What has to give is not the protective function of the welfare state — which we still need. What has to give is the unspoken assumption that the system is best used as a long-stay, low-intensity holding pattern.”
— Prof. Dr. Ying Zhang, on sick-leave reform
Five reform directions
The essay closes with a five-point reform programme. First, another round of reform of the PEPP/PsychVVG inpatient reimbursement regime, which Zhang argues structurally under-finances guideline-level psychosomatic care. Second, properly financed further-training pipelines for psychotherapists and psychosomatic physicians, where a 2019 reform left an unresolved funding gap. Third, national investment in routine PROM/PREM measurement for mental health, along the lines proposed by the OECD’s 2025 working paper. Fourth, a reframing of the cultural conversation about sick-leave entitlement — distinguishing certificates that bridge to rapid rehabilitation from those that bridge to nothing. Fifth, the formation of a private-clinic-owner forum to coordinate sector-level reform, an invitation Zhang extends explicitly in the essay.
ABOUT THE ARTICLE
Zhang, Y. (2026). The system that eats itself: From Wirtschaftswunder to Wartezimmer — A personal view of the German mental health care sector. Singularity Academy Frontier Review, 2026(No. 05·20), Article SAFR 20260526. Published under a Creative Commons Attribution 4.0 International (CC BY 4.0) licence. DOI: https://zenodo.org/records/20395186
ABOUT SINGULARITY ACADEMY FRONTIER REVIEW
Singularity Academy Frontier Review (ISSN 2813-3641) is the peer-reviewed open-access journal of Singularity Academy, Switzerland. It publishes perspective essays, empirical research, and policy work at the frontier of health, technology, education, and the social sciences.
ABOUT THE VERUS CARE GROUP
The Verus Care Group (www.veruscare.org) is a Swiss-invested mental health group operating two private psychosomatic clinics in Germany — the Verus Libori Klinik in Todtmoos (Schwarzwald) and the Verus Bonifatius Klinik in Bad Salzschlirf (Hessen). The group delivers psychiatry, psychotherapy, and psychosomatic medicine to adults, children, adolescents, and families, with onsite and online care.
ABOUT SINGULARITY ACADEMY
Singularity Academy is a Switzerland-based academy concerned with the next generation of clinicians, researchers, and policy thinkers across health, technology, and the human sciences. It collaborates with international universities and research institutes and operates a Global Talent Program for early-career psychologists.
MEDIA CONTACT
Prof. Dr. Ying Zhang · President, Singularity Academy · zhang@singularityacademy.ch
Interview requests, advance review copies of the article, and high-resolution Figure 1 are available on request. The article is published open-access under CC BY 4.0; full text and figures may be reproduced with attribution.
German Version:
Privatklinikinhaberin Prof. Dr. Ying Zhang argumentiert, dass steigende Nachfrage, schrumpfende öffentliche Kapazitäten, ein Zwei-Klassen-Versicherungssystem und eine erschöpfte Belegschaft sich gegenseitig verstärken — und legt fünf strukturelle Reformvorschläge vor.
ZÜRICH / TODTMOOS/ FULDA 26. Mai 2026 — Das deutsche Versorgungssystem für psychische Gesundheit hat sich in eine sich selbst verstärkende Strukturkrise verwickelt — einen „Teufelskreis", in dem Patientennachfrage, klinische Kapazität, Versicherungsstruktur und Burnout der Belegschaft den gesamten Sektor gemeinsam nach unten ziehen. Das ist die zentrale These eines heute veröffentlichten Perspektiv-Essays in Singularity Academy Frontier Review (ISSN 2813-3641; Artikel SAFR 20260520). Ungewöhnlich ist die Autorenposition: Prof. Dr. Ying Zhang ist nicht akademische Beobachterin des Systems, sondern dessen Betreiberin. Sie ist Inhaberin der Verus Care Group, einer schweizerisch investierten Klinikgruppe mit zwei psychosomatischen Privatkliniken in Deutschland, und Präsidentin der Singularity Academy in der Schweiz.
Zahlen, die in eine Richtung weisen
Zhang stützt ihre Argumentation auf die aktuellsten Bundesdaten. Die panel-basierte Schätzung depressiver Symptome in der erwachsenen Bevölkerung durch das Robert Koch-Institut stieg von 7,5 Prozent im Jahr 2020 auf 14,8 Prozent im Jahr 2023 — eine annähernde Verdoppelung in drei Jahren. Der DAK-Psychreport 2024 verzeichnet psychisch bedingte Krankheitstage auf einem neuen historischen Höchststand. Die durchschnittliche Wartezeit auf eine erste ambulante psychotherapeutische Sitzung beträgt in ländlichen Regionen mittlerweile zwanzig bis vierundzwanzig Wochen, so die Bundespsychotherapeutenkammer.
Das Angebot bewegt sich in die entgegengesetzte Richtung. Die Zahl der stationären psychiatrischen und psychosomatischen Betten in der gesetzlichen Versorgung sinkt seit Anfang der 2010er-Jahre, und die European Mental Health Roadmap spricht von einem europaweiten Defizit von rund 1,2 Millionen Gesundheitsfachkräften — mit Burnout in der eigenen Berufsgruppe als beschleunigendem Faktor.
“Die Nachfrage steigt. Das Angebot hält sich bestenfalls stabil. Das System rationiert die psychische Versorgung strenger als die somatische, und die Rationierung trifft jene am härtesten, die am wenigsten warten können.”
— Prof. Dr. Ying Zhang, Singularity Academy Frontier Review (2026)
Zugang nach Versicherungsstatus rationiert
Rund 89 Prozent der Bevölkerung in Deutschland sind in der gesetzlichen Krankenversicherung (GKV), etwa 11 Prozent privat (PKV) versichert. Für die meisten somatischen Erkrankungen ist diese Aufteilung eine Unannehmlichkeit. Für die psychische Versorgung, so Zhang, ist sie ein „Abgrund": Privatversicherte berichten von deutlich kürzeren Wartezeiten, gesetzlich Versicherte sind weitaus häufiger von überlangen Wartezeiten betroffen. Privatkliniken, die ihre Kapazität ausbauen könnten, können dies zu gesetzlichen Sätzen nicht nachhaltig tun — Sätze, die nach Zhangs Einschätzung die tatsächlichen Kosten guter Versorgung nicht decken.
Eine kulturelle Diagnose — mit Beitrag von außerhalb der Klinik
Der Essay greift auf Byung-Chul Hans „Müdigkeitsgesellschaft" und auf Alain Ehrenbergs „La fatigue d’être soi" zurück, um zu zeigen, dass deutsche Patientinnen und Patienten zunehmend nicht mit Konflikten, sondern mit Unzulänglichkeit in die Klinik kommen — der Erschöpfung, nicht die Version seiner selbst geworden zu sein, die man sich vorgestellt hatte. Ein neuer Abschnitt in der Mai-Fassung 2026 integriert einen schriftlichen Kommentar von Herrn JK, einem erfahrenen IT-Fachmann mit jahrzehntelanger Erfahrung in deutschen Privat- und öffentlichen Kliniken. JK beschreibt einen messbaren generationellen Wandel in Belastbarkeit und Stresstoleranz bei den nach 1995 Geborenen. Zhang behandelt diese Beobachtung als ernstzunehmenden empirischen Befund und verknüpft sie mit der Trendstudie Jugend in Deutschland 2025 und der 19. Shell Jugendstudie, die übereinstimmend erhöhten Stress, Erschöpfung und Bedarf an psychologischer Unterstützung bei jüngeren Deutschen dokumentieren.
Eine fiskalische, nicht nur klinische Frage
Zhang stellt die klinische Analyse in den Kontext der angespannten Haushaltslage Deutschlands. Die 2025 beschlossene Reform der Schuldenbremse und das Sondervermögen über 500 Milliarden Euro waren — so ihre Lesart — auch ein Eingeständnis, dass die bestehende Regel die akkumulierten Verpflichtungen des Sozialstaats nicht mehr finanzieren konnte. Schätzungen des Verbands Forschender Arzneimittelhersteller beziffern die volkswirtschaftlichen Kosten krankheitsbedingter Fehlzeiten auf rund vierzig Milliarden Euro jährlich — knapp ein Prozent des Bruttoinlandsprodukts —, wobei psychische Diagnosen nach Atemwegsinfektionen mittlerweile zweithäufigster Grund für Krankschreibungen sind.
“Was aufgegeben werden muss, ist nicht die Schutzfunktion des Sozialstaats — die brauchen wir weiterhin. Aufgegeben werden muss die unausgesprochene Annahme, das System sei am besten als langwierige, niedrigintensive Wartezone zu nutzen.”
— Prof. Dr. Ying Zhang zur Reform der Arbeitsunfähigkeitsbescheinigung
Fünf Reformrichtungen
Der Essay schließt mit einem Fünf-Punkte-Reformprogramm. Erstens: eine weitere Reform des PEPP/PsychVVG-Vergütungssystems für stationäre psychiatrisch-psychosomatische Versorgung, das nach Zhangs Analyse leitliniengerechte Behandlung strukturell unterfinanziert. Zweitens: eine ordnungsgemäß finanzierte Weiterbildung für Psychotherapeutinnen und Psychotherapeuten sowie für ärztliche Psychosomatik — eine Lücke, die die Reform von 2019 ungelöst gelassen hat. Drittens: ein bundesweiter Aufbau standardisierter PROM/PREM-Routinemessung für die psychische Versorgung, entlang der Linien, die das OECD-Arbeitspapier von 2025 vorgezeichnet hat. Viertens: eine Neuverortung der öffentlichen Debatte über Krankschreibungen — mit klarer Unterscheidung zwischen Bescheinigungen, die zu schneller Rehabilitation überleiten, und solchen, die ins Nichts führen. Fünftens: die Gründung eines Forums der Privatklinikinhaber zur Koordination sektorweiter Reformvorschläge — eine Einladung, die Zhang im Essay ausdrücklich ausspricht.
ÜBER DEN ARTIKEL
Zhang, Y. (2026). The system that eats itself: From Wirtschaftswunder to Wartezimmer — A personal view of the German mental health care sector. Singularity Academy Frontier Review, 2026(No. 05·20), Artikel SAFR 20260520. Veröffentlicht unter einer Creative Commons Namensnennung 4.0 International (CC BY 4.0) Lizenz. DOI: https://zenodo.org/records/20398185
ÜBER DIE SINGULARITY ACADEMY FRONTIER REVIEW
Die Singularity Academy Frontier Review (ISSN 2813-3641) ist die begutachtete Open-Access-Zeitschrift der Singularity Academy, Schweiz. Sie veröffentlicht Perspektiv-Essays, empirische Forschung und Beiträge zur Politikgestaltung an der Schnittstelle von Gesundheit, Technologie, Bildung und Sozialwissenschaften.
ÜBER DIE VERUS CARE GROUP
Die Verus Care Group (www.veruscare.org) ist eine schweizerisch investierte Klinikgruppe für psychische Gesundheit mit zwei psychosomatischen Privatkliniken in Deutschland — der Verus Libori Klinik in Todtmoos (Schwarzwald) und der Verus Bonifatius Klinik in Bad Salzschlirf (Hessen). Die Gruppe bietet Psychiatrie, Psychotherapie und Psychosomatik für Erwachsene, Kinder, Jugendliche und Familien an, stationär und online.
ÜBER DIE SINGULARITY ACADEMY
Die Singularity Academy mit Sitz in der Schweiz widmet sich der nächsten Generation von Klinikerinnen, Forschenden und politischen Denkenden an der Schnittstelle von Gesundheit, Technologie und Humanwissenschaften. Sie arbeitet mit internationalen Universitäten und Forschungsinstituten zusammen und betreibt ein Global Talent Program für junge Psychologinnen und Psychologen.
About the article:
The System That Eats ItselfFrom Wirtschaftswunder (economic miracle) to Wartezimmer (waiting room) — A Personal View of the German Mental Health Care Sector
SINGULARITY ACADEMY FRONTIER REVIEW
ISSN 2813-3641 · Vol. 2026, No. 05·26 · Published 26 May 2026 Article SAFR 20260526
PERSPECTIVE · HEALTH POLICY & PSYCHOSOMATIC MEDICINE
The System That Eats Itself
From Wirtschaftswunder (economic miracle) to Wartezimmer (waiting room) — A Personal View of the German Mental Health Care Sector
Prof. Dr. Ying Zhang ¹,²,*
¹ Chairwoman, Verus Care Group, Germany.
² President, Singularity Academy, Switzerland.
* Correspondence: zhang@singularityacademy.ch
Article type: Personal View / Perspective Essay
Received: 12 March 2026 Revised: 20 May 2026 Accepted: 26 May 2026 Published: 26 May 2026
Article identifier: SAFR 20260526
© 2026 The Author. Published by Singularity Academy under a Creative Commons Attribution 4.0 International (CC BY 4.0) licence.
DOI:10.5281/zenodo.20395186
Abstract
Background. Germany’s mental health care system, despite high health expenditure and a long tradition of psychosomatic medicine, has entered a period of severe structural strain. The Robert Koch Institute panel data show that the share of adults at or above the depression-screening cut-off rose from 7.5% in 2020 to 14.8% in 2023 (RKI, 2025; Hapke et al., 2025). Mental illness–related work absences reached a new historical maximum in 2024 (DAK-Gesundheit, 2024), and average waiting times for outpatient psychotherapy now exceed twenty weeks in rural regions (BPtK, 2025).
Position. In this Personal View, I argue — as the owner of a private psychosomatic clinic group operating inside this environment, and as the president of an academy concerned with the next generation of clinicians and researchers — that the German mental health field has entered a dead loop in which rising demand, contracting public capacity, structurally unprofitable private capacity, a two-tier insurance system that rations access by tier, and a workforce that is itself burning out, mutually reinforce one another. I draw on the sociology of burnout (Han, 2015; Ehrenberg, 2010), the individualisation thesis (Beck & Beck-Gernsheim, 2002), the empirical literature on family-system and psychosomatic care (Minuchin et al., 1978; Linden & Bernert, 2014; Köhler et al., 2023), and the value-based healthcare framework (Porter & Teisberg, 2006) to make the case that a holistic, individualised, family-centred model of psychosomatic care is both clinically necessary and, in the medium term, economically rational.
Personal vision. My driving purpose, in everything I do at the Verus Care Group and at Singularity Academy, is to help families and children find a way out of what I have come to call the mental disorder trap — the recursive cycle in which an underfunded system, an exhausted workforce, and a culturally normalised disease vocabulary together imprison individuals and their families inside diagnostic identities they cannot escape and that the system, as currently configured, cannot help them resolve. I am especially concerned with mothers and children, because the next generation’s mental health is decided largely by what happens inside the family system in the early years.
Conclusion. The essay proposes five concrete reform directions: reform of the PEPP/PsychVVG reimbursement regime so that high-quality psychosomatic inpatient care is not structurally unprofitable; properly financed psychotherapy and psychosomatic further-training pipelines; national investment in routine PROM/PREM measurement for mental health; a reframed cultural conversation about sick-leave and rehabilitation; and the formation of a private-clinic-owner forum to coordinate sector-level reform.
Keywords psychosomatic medicine; Germany; burnout society; family systems therapy; mental disorder trap; PEPP/PsychVVG; private clinics; value-based healthcare; individualisation; mothers and children; Verus Care Group; Singularity Academy.
About the Verus Care Group
The Verus Care Group (www.veruscare.org) is a Swiss-invested mental health group with clinical operations in Germany. We provide professional medical services in psychiatry, psychotherapy, and psychosomatic medicine, delivered both onsite and online — combining intensive inpatient and day-clinic treatment with digital continuity of care where it is clinically appropriate.
Our clinical focus reaches across children and adolescents, adults, and — increasingly central to our model — the family system as a whole. Patients and their families receive structured, multidisciplinary support during acute psychological and psychosomatic crises, in a therapeutic and communicative culture that is clinically precise and respectful of each patient’s individual life context. We work international, multilingually, and with a deliberate cultural sensitivity, supporting patients from a wide range of linguistic, cultural, and familial backgrounds.
Two flagship clinics currently anchor the group. The Verus Libori Klinik (Hauptstraße 3, 79682 Todtmoos, in the Schwarzwald, near the Zürich and extended Freiburg regions) offers integrated treatment pathways for adults and for children and adolescents, including family-oriented programmes set in the natural environment of the Black Forest — Wer den Weg zur Natur findet, findet auch den Weg zu sich selbst. The Verus Bonifatius Klinik (St.-Vinzenz-Allee 1, 36364 Bad Salzschlirf, in Hessen, in the extended Frankfurt / Rhein-Main region) specialises in therapeutic settings that support families and parent-child treatment — Wege aus der Krise entstehen Schritt für Schritt — gemeinsam.
Beyond clinical service, the Verus Care Group works actively with international universities and research institutions to develop evidence-informed standards of care, conduct research, and build innovative programmes — for the well-being of families and of the next generation. We have been participating in an Global Talent Program, in cooperation with universities and research institutes worldwide, that develops outstanding young psychologists through structured clinical exposure, practice-based learning, supervision, and continuous development pathways.
We are currently on an active growth trajectory. Our ambition is to be among the leading providers of mental health care globally — to redefine what the international gold standard of such care looks like, to rethink how it is delivered, and to renew hope for patients and families wherever they are. The essay that follows should be read in that context. It is the argument of a clinician and an owner who believes that the German mental health system, as currently configured, is structurally failing the people it is meant to serve, and who is building an institution intended both to serve those people directly and to demonstrate, in practice, what better is possible.
Figure 1 — Concept Graph
Figure 1. Concept graph of "The System That Eats Itself". Layers 1–2 trace the causal apparatus (sociology, generational shift, family erosion, demand/supply/insurance pressures) that feeds Layer 3, the central thesis of the dead loop. Layer 4 names the two consequences (the mental disorder trap; the fiscal cost) and Layer 5 the response (the Verus model and the five reform directions of Section 8).
1. Introduction: the mental disorder trap
I want to begin with the personal vision that underwrites everything that follows.
My purpose, in all of the work I do, is to help families and children find a way out of what I call the mental disorder trap. By the mental disorder trap I mean something quite specific: the recursive cycle in which a person — most often, in my experience, a mother, a child, or an adolescent — encounters distress, encounters a healthcare system that is too slow, too thinly staffed, and too economically misaligned to respond to that distress on time, and then, in the interval, encounters a dense vocabulary of psychiatric and psychosomatic categories with which to name the distress. The naming becomes an identity. The identity becomes the entry point to a system that is not able to discharge it back to wellness. The person is, in the most literal sense, trapped inside the diagnosis the system gave her — held there by waiting lists, by the absence of family-system support, by the workplace dynamics that produced the distress in the first place, and by a culture that increasingly speaks of itself in clinical terms. This trap is not the patient’s fault. It is a structural property of the system as currently configured. The argument of this essay is that we know enough, clinically and economically, to dismantle it; that the people running the system are not, at present, dismantling it; and that those of us in a position to do so are obliged to try.
I write as the president of Singularity Academy in Switzerland, an academy concerned with the next generation of clinicians, researchers, and policy thinkers, and as the owner of the Verus Care Group in Germany. The two roles are connected. The Verus Care Group is where the clinical care happens — where I and my colleagues see, every working day, what the trap I just described looks like in actual lives. Singularity Academy is where I attempt to do the upstream work: to train the people who will, in the next decade, decide whether the trap continues to function or is dismantled. The essay that follows is in the first person because the position I am writing from is a particular position — neither neutral observer nor disengaged academic — and the reader is entitled to know that.
We operate two private clinics in Germany — the Verus Libori Klinik in Todtmoos, in the Schwarzwald, Germany, and the Verus Bonifatius Klinik in Bad Salzschlirf, in Hessen, Germany. Our work is psychiatry, psychosomatic medicine, and psychotherapy, and most of our patients come to us in some form of crisis: burnout, depression, anxiety, somatic symptom disorders, the long aftermath of a life that has stopped making room for the person living it. They arrive with what I sometimes call their little universe — their work, their family, their habits, sometimes their faith — partially or wholly broken. Our job, as I see it, is to help them put it back together in a form that can survive contact with the rest of their lives. And because the patients we see are very often parents, and because most of the parents we see are very often mothers, the work we do with them is, in effect, work with the families and children they belong to. The next generation’s mental health is decided largely by what happens inside the family system in the early years (Walsh, 2015; Steinhardt et al., 2025). That is why mothers and children are, for me, the center of the work.
I have been doing this work for long enough now that I have stopped being surprised by the gap between what the German healthcare system is described as, in international rankings and policy documents, and what it actually feels like to operate inside it. The country invests around twelve per cent of GDP in health (Commonwealth Fund, 2025). It has the longest tradition in the world of treating psychosomatic medicine as an independent specialty (Linden & Bernert, 2014). It has more inpatient beds, per capita, than almost any of its neighbours. And yet, when I sit with families on the phone trying to get a person into care, I am repeatedly confronted with the same fact: the system has nowhere to put them. Public clinics are closing or contracting. Private clinics, including mine, are working at capacity. Outpatient psychotherapists in the statutory system have waiting lists measured in months. Insurance companies behave as if the problem will go away if they look the other way for long enough.
This is the contradiction I want to write about. I want to describe what the people inside the system can see, but the people who write the rules apparently cannot. I want to be honest about my own position in it — I am not a neutral observer, I am a private clinic owner, and I have financial as well as moral skin in the game. And I want to use the empirical literature, where it helps, to anchor what would otherwise be one practitioner’s impressions. The essay has seven further sections. The first is a description of the system as I see it — what I have been calling a dead loop. The next two are an attempt to think about why we got here, drawing on contemporary social theory of burnout and on a generational shift in Germany that a recent commentary by Mr. JK has helped me put into words; this second strand also asks how much fiscal capacity the federal republic still has, to allow the present arrangement to continue. The fourth turns to the sociology of the family. The fifth is about the unresolved tension at the heart of running any psychosomatic clinic in Germany today, the tension between economics and quality. The sixth describes the model of care we are trying to build at Verus. The seventh sets out what I think actually needs to change.
2. A system that eats itself
Let me start with the demand side. The Robert Koch Institute publishes a panel-based estimate of depressive and anxiety symptoms in the German adult population. In 2020, about 7.5 per cent of adults were at or above the depression screening cut-off. In 2023, the figure was 14.8 per cent (RKI, 2025; Hapke et al., 2025). The prevalence essentially doubled in three years. Anxiety has risen in parallel. The DAK Psychreport 2024 shows that mental illness-related work absences have reached a new historical maximum, with depressive disorders, chronic exhaustion, and anxiety leading the increase (DAK-Gesundheit, 2024). When we look across the European Region, WHO estimates that roughly seventeen per cent of adults have a diagnosable mental disorder at any given time, and that only about two thirds of those affected receive any care (Reinhold et al., 2025; The Lancet Regional Health – Europe, 2025).
These are not small numbers. If even a fraction of the people who meet criteria for moderate depression were to seek inpatient or intensive outpatient care, the system as currently configured would collapse. It does not collapse only because most of them never make it through the queue. The Bundespsychotherapeutenkammer reports that the average waiting time between an initial consultation and the first psychotherapy session is around twelve weeks in urban areas and twenty to twenty-four weeks in rural areas (BPtK, 2025; ZDF, 2025). When we follow up with patients who eventually find their way to one of our clinics, many of them describe a period of six months to a year between recognising they need help and actually receiving it.
Now look at the supply side. The number of statutory hospital beds in psychiatric and psychosomatic departments in Germany has been declining in absolute terms since the early 2010s. Mental health services research has consistently identified psychiatry, psychotherapy, and psychosomatic medicine as the disciplines facing the most severe staffing deficits, with the gap projected to widen (Härter et al., 2025). The European Mental Health Roadmap describes a continent-wide shortfall of approximately 1.2 million health workers, with burnout among professionals themselves accelerating attrition (Reinhold et al., 2025). I see this in our own recruiting. The competition for senior psychosomatic physicians is so intense that wages have risen sharply without any corresponding improvement in clinical productivity. When demand outruns supply in a thin labour market, the price of labour rises and the quality of labour does not.
And then there is the structure of insurance. Around 89 per cent of Germans are covered by gesetzliche Krankenversicherung (statutory health insurance, GKV) and about 11 per cent by private Krankenversicherung (PHI) (Commonwealth Fund, 2025; Feather, 2025). For most somatic conditions, this is an inconvenience. For mental health, it is a chasm. Privately insured patients report substantially shorter waiting times, and the probability of excessive waiting is consistently higher for statutorily insured patients (Heinrich et al., 2018). The system rations mental health care more strictly than it rations somatic care, and the rationing falls disproportionately on the patients who can least afford to wait.
Put these three pictures together and you get what I described to Sophie Oder as a dead loop. Demand is rising. Supply is at best holding steady and in some segments shrinking. The pricing mechanism that would, in a normal market, equilibrate the two is blocked: the patients who most need care are statutorily insured at prices that do not cover what good care actually costs, and the suppliers most willing to expand capacity — private clinics — cannot expand sustainably at those prices. So the public system rations through queues, the private system rations through cost-sharing, and the population in the middle waits.
I want to be careful not to overstate the originality of this observation. Anyone running a clinic in Germany knows it. What is surprising is how rarely the people designing the rules behave as if they know it. Insurance companies continue to negotiate budgets as if the population’s mental health were stable. The federal government continues to underfinance hospital infrastructure and training. The Bundespsychotherapeutenkammer’s 2025 position paper called, again, for separate needs planning for child and adolescent care, for funded specialist further training, and for an expansion of intensive psychotherapeutic inpatient services (BPtK, 2025). Most of these proposals are not new. Most of them are not radical. They have been on the table for years.
Meanwhile, patients come. We treat them. We treat them at prices that, for the statutorily insured share of our population, do not cover what their care actually costs us. We absorb the difference. I will return to that below.
3. The burnout society we built
How did we get here? Demand for mental health care, of the kind I have just described, is not just a function of clinical supply. It is a function of how people live, how they work, how they think about themselves. And on that level the German story has a paradox at its centre. This is the country that built the strongest worker protections in Europe, the longest paid vacations, the most generous sick-leave entitlements. Work-life balance is a national vocabulary item. And yet the rates of burnout, exhaustion, and mood disorder keep rising. Why?
I find Byung-Chul Han’s diagnosis useful here. In The Burnout Society (Han, 2015), he argues that the disciplinary society Foucault described — a society organised around external prohibitions, around what you are not allowed to do — has been replaced by what he calls a Leistungsgesellschaft, an achievement society, organised around an internal imperative to optimise. The pathologies of this society are not infections caused by something the subject was forbidden to take in. They are infarcts caused by an excess of positivity. Depression, attention disorders, borderline phenomena, and burnout are its emblematic conditions. The achievement-subject exploits itself until it burns out (Han, 2015, pp. 8–10).
I think Han is essentially right. The paradox of Germany is not really a paradox. The same conditions that produced strong worker protections also produced an unusually articulate culture of self-management. The German middle class is one of the most psychologically literate populations in the world. People here know the vocabulary of work-life balance, mindfulness, resilience, attachment styles, attachment wounds. They speak this vocabulary fluently. And the speaking of it is not the cure for the condition; it is, increasingly, an additional dimension of the condition. The injunction to balance your life becomes another performance metric. The injunction to be authentic becomes another project you can fail at. We are constantly told we should rest, and the resting itself becomes a kind of work.
Alain Ehrenberg, in La fatigue d’être soi (Ehrenberg, 2010), makes a complementary argument. The rise of depression in late-modern societies, he says, tracks a cultural shift from a morality of conflict to a morality of insufficiency. In an older society, you suffered because you had violated a prohibition, or because someone had violated one against you. In our society, you suffer because you have failed to become the version of yourself that you imagined you could become. The fatigue is the fatigue of being oneself. I see this in our patients constantly. They do not present, mostly, with conflicts. They present with insufficiency. I should be further along by now. I should have been able to handle this. I do not understand why I am the way I am.
Now I will be more polemical, and I will mark it as such. When I spoke with Sophie, I said that I think Germans are too quick to take themselves out of work. I said that if you sneeze three times a day in many parts of the world, you go to work; in Germany, that is considered a sickness, and you stay at home. I stand by the observation, but I want to be more precise about it than I was in the conversation. I do not think German patients are weak. I do not think they are imagining their suffering. What I think is that we have built a system in which a very generous compensation regime — up to six weeks of full salary continuation for the same illness, sick certificates available from the Hausarzt with relatively little friction — coexists with an under-funded rehabilitation and outpatient infrastructure. We pay people to be incapacitated. We do not pay nearly enough to help them stop being incapacitated. The result is that the average German employee now takes around fifteen sick days a year, with an estimated economic cost of around 82 billion euros annually (Fortune, 2026). Mental health conditions account for around seventeen per cent of those absence days (DAK-Gesundheit, 2024).
I want to insist that none of this means the people on sick leave are malingering. The longitudinal cohort evidence shows that depression- and anxiety-related sick leave in Germany is a strong predictor of later permanent disability and even of elevated mortality (Hjarsbech et al., 2014). The same certificate that, for one patient, is a low-friction exit from work is, for another, the only thing standing between her and an acute decompensation. The system is doing real protective work, and we should not dismantle it. What we should do is invest in the rehabilitative throughput that shortens the episodes. A sick certificate that leads, in three weeks, to an intensive outpatient programme is doing one thing. A sick certificate that leads to six months of unsupported isolation is doing something quite different.
There is one more sociological factor I want to name. The labelling-theory tradition in medical sociology, going back to Scheff (Scheff, 1966) and refined in contemporary cultural psychiatry, observes that the way symptoms are expressed is sensitive to the categorical resources a culture makes available. This is not the same as saying the suffering is unreal. It is saying that the same underlying load of distress takes different forms in different cultural systems. The German system makes psychiatric and psychosomatic diagnostic categories broadly available, has comparatively low stigma about them, and has high willingness to certify incapacity. It would be remarkable if such a system did not produce, at the population level, more patients who arrive at a clinic having already labelled themselves. It does not follow that they should not be there. It does follow that the system needs to be capable of moving them through care, not parking them at the door.
4. Old and young Germans: a note prompted by Mr. JK
After an early draft of this essay was circulated, Mr. JK — a senior IT professional with whom I have worked, and who has spent decades inside both private and public clinics in Germany — sent me a commentary that sharpened, more than any other reader’s response, the argument I had been trying to make in the preceding section. I want to reproduce his words at length, because the diagnosis is more useful in his voice than it would be in mine:
“The article provides a remarkably honest analysis of the structural imbalances in the German psychosomatic care system. The picture of rising demand, shrinking public capacity, underfunded private providers, access rationed according to insurance status captures the reality indeed. This is an issue that is of great concern to many Germans.”
“In my view, however, it is also important to mention that younger generations in Germany have been rather spoilt by the education system over the past two to three decades and have since developed a problematic attitude towards criticism and the ability to perform. In my personal experience, there have been many mistakes and misjudgements in this regard, from both government decisions and parental upbringing.”
“These days, both in my professional and personal life, I come across many issues where everyday challenges (such as the commute from Düsseldorf to Cologne for one of our employees) lead to people taking sick leave due to mental strain. Particularly in larger conurbations such as Berlin, Cologne or Hamburg, I am hearing more and more often that young people in their early 20s feel as though a lot of them are in therapy or are at least planning to be. Compared to the early 2000s, this is a massive shift, especially as it was an absolute no-go topic in Germany back then.” (JK, personal communication, April 2026)
I take Mr. JK’s observation seriously, and I want to explain why. Mr. JK belongs, professionally and culturally, to what I would call the “old German” type, even though he himself is a young-aged gentleman — and I mean that with respect, not nostalgia. He works in the mode of the Aufbaugeneration, the cohort that absorbed, from parents and teachers shaped by the post-war reconstruction, the habit of disciplined work, low complaint, durable commitment, and a long time horizon. Contemporary economic historians repeatedly note that the rapid productivity gains of the Wirtschaftswunder were attributable not only to the Marshall Plan and to the social market economy of Ludwig Erhard, but to a workforce whose habits — Sparsamkeit, Pflichtbewusstsein, Leistungsbereitschaft — had been forged first in scarcity and then in reconstruction (Abelshauser, 2011). What the Aufbaugeneration knew, and what its children still inherited, was that work could be hard, that criticism was information rather than injury, and that one did not exit the field at the first sign of strain. Mr. JK carries those dispositions into his daily practice. They shape how he sees the patient in front of him.
The young Germans whom Mr. JK now sees in his consulting room are a recognisably different population. Most of them were born after 1995 — many after 2000 — into the most secure, most prosperous, most psychologically literate Germany that has ever existed. Their childhoods were shaped by what the German press has called Helikopter-Eltern, parents who out of love and anxiety monitor, intervene, optimise, and protect their children from frustration and risk. The German and Anglo-American developmental literature has by now built an extensive critique of this style: the price of intensive parental protection is that the child does not adequately develop frustration tolerance, does not learn to recover from failure, and does not learn to take criticism as information rather than as a wound (Schiffrin & Liss, 2017). The school system has shifted, in parallel, along the same axis. Two and a half decades of reforms — grade compression, reduced exposure to performance pressure, expanded availability of psychological accommodation — were intended to be humane and were, on the margin, often correct. Cumulatively, however, they have produced a cohort that arrives at adulthood with a thinner default tolerance for criticism and friction than its predecessors had. This is, in essence, what Mr. JK is naming when he speaks of mistakes and misjudgements both at the level of government decisions and at the level of parental upbringing.
The empirical picture matches his clinical impression. The Trendstudie Jugend in Deutschland 2025 (Schnetzer, Hampel & Hurrelmann, 2025), a representative survey of more than six thousand Germans aged 14 to 69, reports that 46 per cent of 14–29-year-olds describe themselves as suffering from stress, 35 per cent from exhaustion, 33 per cent from self-doubt and 24 per cent from irritability; the corresponding figures for the 50–69 cohort are roughly a third of these. Twenty-nine per cent of young Germans now say they need psychological support, and among those out of work the figure rises to 42 per cent. The 19. Shell Jugendstudie (Shell Deutschland, 2024) reaches a complementary verdict: today’s youth are pragmatic and articulate, but mental health, work–life balance, and the perceived inability to keep up with what the world is asking of them have moved to the centre of their self-description. Panel work on the post-pandemic period shows, further, that depression and anxiety in young German adults remain markedly elevated above pre-pandemic baselines — the authors of one recent preprint describe the phenomenon as post-pandemic persistence rather than recovery (Reiss et al., 2025).
The sick-leave picture confirms what Mr. JK sees from inside the workplace. Aggregate German sickness absences are now at a level no developed economy has historically considered normal. Recent estimates from the Verband Forschender Arzneimittelhersteller place the macro-economic cost at roughly forty billion euros a year and the lost value-added at close to one per cent of annual GDP; over the four years 2022–2025, the cumulative shortfall has been put at up to one hundred and sixty billion euros (Eulerpool, 2026; Fortune, 2026). Mental-health diagnoses are no longer a marginal line item in this picture: after respiratory infections they are now the second most cited cause of sick days, and they are still rising (DAK-Gesundheit, 2024). The case Mr. JK mentions — the employee who converts the Düsseldorf-to-Cologne commute into a certified incapacity — is no longer the rare outlier. Among Generation Z employees, the disposition to translate a moderately taxing situation into a sick certificate is measurably higher than in older cohorts (Fortune, 2026). Mr. JK’s polemic and the published macro data point in the same direction.
A second strand of evidence places the German experience inside a wider story. Jonathan Haidt’s recent synthesis (Haidt, 2024), building on Jean Twenge’s longitudinal work (Twenge, 2017), argues that the years between 2010 and 2015 — when the smartphone became universal, social media became continuous, and unsupervised real-world play collapsed — produced a “great rewiring of childhood” whose mental-health effects are now visible across the entire industrialised world. The thesis is contested in detail (Odgers, 2024), but the patterns it describes — sharp rises in adolescent anxiety, depression, and self-harm from around 2012, especially in girls — are visible in the German data as well. Alongside this attentional and affective rewiring, the German evidence also points to a parallel physical decline. Successive cohort studies document a secular fall in aerobic fitness, motor coordination, and overall physical activity in German children and adolescents, with a parallel rise in overweight and obesity (Germany’s Report Card on Physical Activity, 2024); even in young recruits to the Bundeswehr, BMI distributions have drifted upward over the past decade (Sammito et al., 2023). The young people Mr. JK and I treat are therefore, on average, not only more anxious and more medicalised than their parents were at the same age, but also less physically robust. They arrive in our clinics with thinner reserves on every dimension.
This is, I think, the deeper meaning of what Mr. JK is saying. The challenge is not that today’s young Germans suffer less than their grandparents did — that comparison is not available to us and would not be useful if it were. The challenge is that they suffer differently, and that the surrounding system — generous sick-leave entitlement, low-friction certification, high cultural fluency in psychiatric vocabulary, parental and educational habits oriented toward protection from challenge — converts a given dose of distress into a substantially longer episode of incapacity than it would have done in Mr. JK’s youth. The clinical implication is not less help. The clinical implication is help of a different shape: help that builds frustration tolerance rather than substitutes for it, help that returns the patient to the relational and occupational system rather than excusing her from it, help that re-introduces the experience of mastered difficulty rather than insulating from difficulty altogether. This is, in fact, what good psychosomatic rehabilitation has always tried to do. It is harder to do in 2026 than it was in 1996, because the patient now arrives with thinner default reserves on every axis — physical, attentional, affective, motivational — and because the surrounding culture is less inclined to ask for those reserves to be rebuilt.
The point that follows from this is, in my view, the question the public conversation in Germany has not yet asked in plain language. We have built, layer by layer, a system that promises to absorb the cost of a workforce that is more medicalised, less physically robust, and more readily certified as incapable of work than any predecessor generation. That promise is not free. Forty billion euros a year of lost value creation from sick leave alone is on the order of one per cent of GDP. The shortage of psychotherapists, psychiatrists, and psychosomatic physicians is widening rather than closing. The Bundeswehr, the police, the railways, the hospitals, the Mittelstand — every employer of consequence in this country — is now operating with a structural human-resources deficit that the demographics of the next decade will only deepen. The question is therefore a fiscal question at least as much as it is a clinical one: how much money, how much foundational saving, how much residual capacity does the federal republic still hold in reserve, to allow this system to continue in its current shape?
The honest answer, on the public ledger, is: less than the political class is willing to say. Germany’s debt brake (Schuldenbremse) was rewritten in March 2025 to accommodate a five-hundred-billion-euro extra-budgetary fund for infrastructure and defence, and to lift the borrowing limit on defence spending above one per cent of GDP altogether (Bruegel, 2025). That reform was, among other things, an admission that the existing fiscal rule could not finance the obligations the existing welfare state has accumulated. The IMF’s 2026 Article IV consultation flagged medium-term sustainability concerns; the OECD’s 2025 Economic Survey of Germany flagged labour-shortage and productivity concerns; the federal government has begun, quietly, to commission expert papers on welfare-state modernisation (IMF, 2026; OECD, 2025). What none of these documents quite says — but what every clinic owner, every senior employer, and every honest hospital administrator I know is saying privately — is that we cannot indefinitely fund a system in which the fragility of the working-age population is rising while the supply of clinical capacity is shrinking and the demographic base of the contribution payers is contracting. Something has to give. The political class can choose to be honest about which thing, or it can wait for the bond market or the demographic curve to choose for it.
My own view, which runs through the rest of this essay, is that what has to give is not the protective function of the welfare state — which we still need, and which the most vulnerable patients still depend on. What has to give is the unspoken assumption that the system is best used as a long-stay, low-intensity holding pattern. A sick certificate that bridges to a rapid, intensive, rehabilitative episode — exactly the kind of episode that good psychosomatic care has been able to deliver in Germany for half a century — is a good investment, both clinically and fiscally. A sick certificate that bridges to nothing is a bad one, and the cumulative cost of those bad bridges is what is now eroding the foundational savings of the republic.
This is, in the end, what I want Mr. JK’s commentary to put on the table. He is right that the cultural and developmental shift in the working-age population is real, that the upbringing and education of the post-1995 cohort have not equipped it for friction at the level its grandparents took for granted, and that the workplace is now paying the bill for that mismatch. He is also right that this is “an issue of great concern to many Germans,” even when they are reluctant to articulate it in public. I owe him the acknowledgement, and the next generation of clinicians and policy-makers owes him the honesty of taking the argument seriously rather than dismissing it as an old man’s complaint. It is not a complaint. It is a description, from inside the consulting room, of what the rest of the country can no longer afford to ignore.
5. The family we lost
There is one more thing I want to say about the sociology, because it is the part that most directly shapes how we work at Verus. The patients who come to us are almost never in trouble in isolation. They are in trouble inside a relational system that, in most cases, used to be larger and is now smaller. Their parents are not nearby. Their siblings are not close. Their grandparents, if alive, are at the end of a long road. Their friendships are real but thin. Their marriages, if they have them, are often the only place where they are emotionally exposed, and the marriage is therefore carrying a load no marriage was designed to carry.
This is not unique to Germany, but Germany is an unusually advanced case of it. Ulrich Beck and Elisabeth Beck-Gernsheim, in Individualization (Beck & Beck-Gernsheim, 2002), described how advanced welfare states institutionally produce individualisation: kinship becomes elective, biographies become do-it-yourself projects, and the once-given resources of community, parish, neighbourhood, and extended kin become contingent. The pay-off is autonomy. The cost is the disappearance of the buffering tissue that previously absorbed psychological shocks.
Family-systems research has been documenting the clinical implications of this for half a century. Salvador Minuchin’s work on what he called psychosomatic families (Minuchin, 1974; Minuchin et al., 1978) showed that family-level interventions could shift physiological markers in classical psychosomatic conditions — anorexia nervosa, brittle diabetes, severe asthma. Murray Bowen’s long research programme on differentiation of self — the capacity to maintain one’s emotional autonomy without disengaging from one’s relational system — has consistently linked higher differentiation to better psychological health, better marital quality, and reduced symptomatology (Skowron & Friedlander, 2015; Brown, 2024). More recent meta-analyses of systemic and family-based therapies confirm efficacy across a wide range of conditions (Carr, 2019). For depression specifically, couple-based interventions show effect sizes comparable to individual psychotherapy with the added benefit of reducing relapse risk in partnered patients (Barbato & D’Avanzo, 2020).
I take this evidence base seriously. At Verus, we treat the patient’s little universe — not only the mental little universe but the closest family system and relationships. We invest heavily in couple and family work. When a patient comes to us in burnout, we want to understand what is happening at home, and where it is possible, we want to bring the partner into part of the treatment. We want to teach the patient how to be in a relationship while staying connected to herself. When she finishes her treatment and goes home, the home should be a slightly different home than the one she left.
I will admit that this is the part of our model that the German outpatient system most consistently fails to deliver. Most patients in the statutory system, even when they get to a psychotherapist, get individual sessions. Family work, couple work, intergenerational work — these are still unusual and unevenly reimbursed. And yet the literature on family resilience identifies family cohesion and intergenerational support as among the strongest predictors of recovery from psychiatric episodes (Walsh, 2015; Steinhardt et al., 2025). The COVID-19 pandemic provided an unintended natural experiment on this: in the German data from 2020–2022, the steepest increases in psychological distress were in households with weak external support networks, and the gentlest increases were in households with active intergenerational contact (Steinhardt et al., 2025). The family is not just the context of the illness. It is, very often, the place where the recovery either holds or does not.
I want to add something about teachers and other front-line caregivers, because Sophie asked me about it and I think it matters. If the adults in a child’s life — parents, teachers, coaches — do not themselves have functional stress regulation, the child cannot learn it. Burnout among the helping professions in Europe is, by every estimate I have seen, somewhere around a third of the workforce (O’Connor et al., 2018; Cambridge Core, 2024). The German healthcare workforce in particular shows elevated emotional exhaustion and depersonalization compared to peer countries. This produces a recursive problem. A workforce that is itself burning out cannot deliver high-quality, emotionally available care to patients whose principal diagnosis is exhaustion. Part of why we invest so heavily in continuing education at Verus, including courses with Yale University and the University of Pennsylvania, is that we believe a workforce that is intellectually alive and well supported is the precondition for the kind of care we want to deliver.
6. The economics of quality
I now want to be direct about the part of this picture that other clinic owners and I rarely discuss in public: the economics. There is a structural tension at the heart of psychosomatic medicine in Germany between the economic requirements of running a clinic and the therapeutic quality of the care that the clinic is supposed to provide. I have lived with this tension for years and I do not pretend to have solved it. What I can do is describe it honestly.
Since 2013, the principal payment instrument for psychiatric and psychosomatic inpatient care in Germany has been the Pauschalierendes Entgeltsystem für Psychiatrie und Psychosomatik (PEPP), a per-diem case-mix reimbursement system analogous to the DRG system used in somatic care (vdek, 2025; AOK, 2025). The system was extensively reformed in 2017 by the Psych-VVG, in response to widespread criticism from professional associations, but the basic logic — daily rates scaled by case-mix and length-of-stay phase — remained intact. The criticisms have not gone away (Aerzteblatt, 2024; GKV-Spitzenverband, 2025). First, daily flat rates create an incentive to compress treatment intensity, which makes it harder to do the kind of patient-specific dose escalation that good psychotherapy requires. Second, the personnel structure that PEPP rates presuppose does not match the actual personnel intensity required to deliver care consistent with German S3 guidelines, with chronic underfinancing of staffing as a result. Third, PEPP penalises clinics that admit high-acuity cases whose treatment costs exceed the case-mix-weighted daily rate. The Bundespsychotherapeutenkammer has argued, repeatedly, that PEPP combined with the Personalbemessungsrichtlinie forces clinics into a structural under-resourcing trap (BPtK, 2024).
I think they are right. And I think the labour-market dynamic I described earlier — limited supply of psychosomatic physicians, intense competition, rising wages — is the mirror image of this regulatory problem. The structural answer would be a substantial increase in psychiatric and psychosomatic capacity, financed through the statutory side, accompanied by aggressive expansion of training pipelines. Neither has happened at the necessary pace.
Now, on the clinic side, I have a confession to make: at Verus we are, by my own honest accounting, over-providing quality. Our therapists want to do good work. Our doctors want to do good work. They do not naturally think in economic terms, and when I ask them to, they often resist. We end up with more individual psychotherapy sessions per patient than the daily rate finances, more multimodal therapy hours than the standard package assumes, more time invested in family work and aftercare planning than any of our competitors. Our food is at Michelin level. Our cost base is high. For our privately insured and self-paying patients, the economics work. For our statutorily insured patients, they do not. We essentially subsidise them. I do not say this as a complaint. I say it as a description.
The variable in which this tension becomes most visible is length of stay (LOS). On the pure economics, if a patient stays longer, you earn more. From a medical standpoint, if a patient stays longer than her treatment plan requires, you have failed in some part of the treatment. The empirical literature on German psychosomatic inpatient rehabilitation supports a phasic model of LOS. The multicentre effectiveness studies (Köhler et al., 2023; Liebherz et al., 2025) report an average inpatient stay of around 40.8 days, with clinically meaningful pre-post effect sizes (Cohen’s d ≈ 0.6–0.9) for depression, anxiety, and somatic symptom burden, and sustained effects at six- and twelve-month follow-up for the majority of patients. The earlier consensus work describes a multimodal weekly programme of 20–25 hours, structured around at least three individual and group psychotherapy sessions per week, supplemented by creative, body-oriented, and mindfulness-based therapies, psychoeducation, social work, and psychopharmacological treatment (Linden & Bernert, 2014). Optimal LOS varies by condition, but generally lies in the 6–8 week range for moderate-severity depressive, anxiety, and somatoform disorders.
Our own data, in broad terms, sit inside this distribution. I am acutely aware that some of our patients, by the end of treatment, would prefer to stay longer. The intensively supported, structured, emotionally contained environment we create is a real comfort, and the prospect of return to an unstructured external environment is genuinely difficult. This phenomenon is well described in the literature — sometimes as regression in the service of the treatment setting (Hinshelwood, 2002). It is the reason why patient satisfaction alone cannot serve as the principal indicator of quality in psychosomatic medicine. A clinic that simply lets patients stay until they are bored will maximise satisfaction in the short run and undermine its own therapeutic mission in the long run.
How then do we measure quality? At Verus, we have settled on a five-component framework. The first is health outcomes: are the patients’ symptoms, functioning, and biographical capacity moving in the direction we and they want them to move? The second is patient satisfaction, which we treat as necessary but not sufficient. The third is the medical team’s internal assessment of whether the care being delivered is, in their professional judgement, good. The fourth is the management team’s assessment of whether the service is being delivered reliably and consistently. The fifth — and this is where I depart from the academic consensus — is my own review, as owner, of the economic and foundational data. I do this not because I am trying to optimise for short-term profit, but because the long-term viability of the institution is itself a quality dimension. An institution that fails financially cannot deliver care at all.
This framework owes a great deal to the value-based healthcare model articulated by Michael Porter and Elizabeth Teisberg (Porter & Teisberg, 2006; Porter, 2010), which defines value as patient-relevant outcomes per unit cost across the full cycle of care, and which is increasingly operationalised through patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). The recent scoping work on PROMs in value-based healthcare programmes (Nilsson et al., 2024) shows that systematic PROM measurement is feasible in mental health and is associated with improved shared decision-making, earlier detection of deterioration, and more individualised treatment adjustment. The OECD’s 2025 working paper on PROMoting quality of care through PROMs (OECD, 2025) calls for national-level investment in standardised PROM/PREM frameworks for mental health. Germany has made only partial investment of this kind. We do most of our outcome measurement ourselves, and we publish it where we can.
7. What we do at Verus
Let me describe, in concrete terms, the model of care we are trying to build.
The first principle is individualisation. Most clinics, public or private, deliver a standardised package. Patients are slotted into a pre-existing programme. At Verus, the programme is reverse-engineered from the patient. On admission, a multidisciplinary team builds a tailored therapy plan, with weekly review and reweighting as the patient’s symptom picture evolves. The plan is supposed to evolve: in the first two weeks, frequency of contact is high, individual psychotherapy and medical supervision are dense, structure dominates. In the middle stage, more autonomy is given back to the patient, group work expands, family work begins. In the final stage, the patient is gradually re-exposed to the outside world while still in the supportive frame of the clinic. The frequency curve declines, deliberately. Patients sometimes resist this — I described that in the previous section — and the resistance is a clinical signal, not a satisfaction problem.
The second principle is multimodality. The German tradition of psychosomatic inpatient rehabilitation is already the most ambitious multimodal mental health intervention in routine use in Europe. Approximately 25,000 inpatient beds are dedicated to Psychosomatische Rehabilitationskliniken, treating roughly five per thousand working-age adults per year (Linden & Bernert, 2014). What is distinctive about Verus is the breadth of additional modalities we have integrated: psychotherapy in individual and group formats; body-oriented therapy; sports therapy; music therapy; art therapy; swimming therapy; traditional Chinese medicine therapy (including acupuncture and moxibustion), cooking and shared meals as therapeutic activities; structured language learning and small skill-building activities as cognitive and motivational stimuli. The intuition behind this breadth is that the patient who is sufficiently engaged in the therapeutic environment is the patient who heals, and the engagement is generated by giving her real, varied, dignifying things to do. The literature is broadly supportive: a 2023 systematic review of music-based interventions across mental health populations found moderate effects on mood, anxiety, social functioning, and treatment engagement, especially when music is integrated with other active modalities (Tang et al., 2023). Creative-arts therapies have demonstrated efficacy for body-image disturbance, trauma symptomatology, and resilience (Sanchez et al., 2025). Mindfulness-based stress reduction and mindfulness-based cognitive therapy — the Western clinical descendants of Buddhist mindfulness practice — produce moderate effects on anxiety (Hedges’s g ≈ 0.63) and depression (Hedges’s g ≈ 0.59) across more than thirty randomised trials (Hofmann et al., 2010; Khoury et al., 2013). Body-oriented therapies have moderate-quality evidence in chronic pain, somatoform disorders, and trauma sequelae (Payne et al., 2015).
There is a legitimate question about whether each modality, taken in isolation, is delivered at evidence-supported dose, or whether the multiplicity itself is doing therapeutic work. I think the honest answer is both. We design each modality to be at clinical dose, and we believe the integration — the experience of being in a richly stimulating, emotionally supportive environment with multiple credible avenues for self-expression — is itself therapeutic. There is some support in the literature for this view: perceived choice and active engagement in a stimulating therapeutic environment are themselves predictors of recovery, independently of the specific modality used (Bohart & Wade, 2013). But I take the methodological question seriously, and one of the reasons we invest in our own outcome research is precisely to disaggregate these effects.
The third principle is integration of philosophy and faith. We learn from Eastern philosophy. The contemplative traditions — Buddhist, Daoist, more broadly Asian — have a more developed phenomenology of attention, equanimity, and self-construal than the strictly clinical Western tradition possesses (Williams et al., 2021; Frontiers in Psychology, 2025). I think there is real intellectual humility involved in admitting this, and I think the Western adaptation of mindfulness has sometimes erred in stripping the practice from its ethical and metaphysical context (Purser, 2019). We try to bring the philosophy back in. We also have a Catholic foundation — both clinics carry the names of Catholic saints — and we draw on the Catholic charitable tradition, which has a long history of healthcare delivery in Germany combined with theological reflection on suffering. The empirical literature on religion and mental health is heterogeneous but converges on a modest positive association between religious participation and well-being, especially where strong social networks are involved (Koenig, 2012; VanderWeele et al., 2017). Our foundation is partly the reason we accept statutorily insured patients at below-cost. We view this work, in part, as charity — not charity in the patronising sense, but charity in the older sense of caritas, an active and demanding love for the people in front of us.
The fourth principle is family-system orientation. I described this in section 5. We do not treat patients as if they were unattached individuals. We treat them as nodes in a relational system that they will be returning to. The relational system is, very often, a co-target of the treatment.
The fifth principle is international collaboration. We work closely with universities in Europe and in Asia. We invite professors of psychiatry for teaching and research. We offer programmes drawing on the curricula of various universities. We are recruiting and developing global talent. The model we are trying to build is, in our intent, not just a German model but a model that the global field of psychosomatic and psychiatric care can learn from. Whether we succeed is, of course, an empirical question. The proof will be in published outcome data, replicable protocols, externally validated training programmes. We are working on all three.
8. What needs to change
I want to close with what I think the system actually needs, leaving aside what any single clinic can do.
First, the PEPP/PsychVVG regime needs another round of serious reform. Daily-rate flat reimbursement that does not match the actual personnel structure required by S3-guideline care is not a financing system; it is a structural incentive to provide bad care. The Bundespsychotherapeutenkammer’s critique on this point has been on the table for over a decade and remains essentially uncontested in the professional literature (Aerzteblatt, 2024; BPtK, 2024).
Second, training pipelines need to be expanded and properly financed. The 2019 reform of psychotherapy training in Germany left a serious gap in the funding of further specialist training (Weiterbildung). A generation of young psychotherapists is now waiting to be deployed and is not being deployed because the financing of their continuing training has not been resolved (BPtK, 2025). This is a solvable problem. It is a policy choice not to solve it.
Third, we need a serious national investment in routine outcome measurement. PROM/PREM frameworks should be standardised across the psychiatric and psychosomatic sector, financed publicly, and made interoperable. The OECD has set out the broad lines of what this would look like (OECD, 2025). Until we have such measurement, every clinic is operating in a partial information vacuum, and every reform debate is conducted with anecdote rather than data.
Fourth, the cultural conversation about sick leave needs to be reframed. I think we should be honest about the difference between a sick-leave entitlement that bridges to rehabilitation and a sick-leave entitlement that bridges to nothing. The first does what it is supposed to do. The second creates a population of people who are taken out of work and then left there. Investment in rapid, accessible rehabilitative care is what would close that gap. It is also, in pure economic terms, the cheaper option: the longer-term costs of permanent disability and lost productivity are vastly larger than the costs of the rehabilitation that prevents them.
Fifth, and this is the smallest of the proposals but the one closest to my own daily work: private clinic owners should meet. The owners of the best private psychosomatic and psychiatric clinics in Germany are, in my experience, more often treated as competitors than as colleagues. They are not competitors in any meaningful sense. The patient pool that genuinely needs high-quality private care is large enough for all of us. The shared interest in shaping reform proposals to the federal government, in pooling outcome data, in coordinating on training and recruitment, is overwhelming. I would like to convene such a forum, and I extend the invitation here.
Finally — and this is for the next generation, particularly those, like Sophie Oder, who are entering the field — I want to say something about what this work is for. We are in the business of helping people become healthy. People who work in this field must first be mentally and physically healthy themselves. If you are reading this as a young researcher, a young clinician, a young manager, please take care of yourself. The system you are entering is real, and the suffering inside it is real, and the work is harder than it looks from the outside. But it is also, in my judgement, the most meaningful work a person can do. Help us change the mentality. Help us change the system. Things need to change, because what is at stake is not the balance sheet of a clinic. What is at stake is whether the people who walk through our doors are still recognisably themselves when they walk out.
That is what I am writing for. That is what we are trying to build.
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Declarations
Author. Prof. Dr. Ying Zhang. President, Singularity Academy, Switzerland. Owner, Verus Care Group, Germany (Verus Libori Klinik, Hauptstraße 3, 79682 Todtmoos; Verus Bonifatius Klinik, St.-Vinzenz-Allee 1, 36364 Bad Salzschlirf).
Correspondence. Prof. Dr. Ying Zhang, Singularity Academy, Switzerland. Email: zhang@singularityacademy.ch.
Author contributions. YZ is the sole author. YZ conceived the argument, conducted the integration with the academic literature, wrote the manuscript, and approved the final version.
Personal vision statement. My driving purpose, both at the Verus Care Group and at Singularity Academy, is to help families and children find a way out of the mental disorder trap — the recursive cycle in which an underfunded system, an exhausted workforce, and a culturally normalised disease vocabulary together imprison patients inside diagnostic identities that the system cannot resolve. This essay is part of that work.
Genesis of the essay. This essay grew out of a long conversation I had with Ms. Sophie Oder in Zürich on 20 March 2026. Ms. Oder is a graduate writing her thesis about the private clinic sector in Germany; her twelve questions over the course of our interview pushed me to put into words things I think about every day but rarely sit down to write. An early draft of the essay was then circulated for comment; a substantive written response from Mr. JK— a senior IT professional with extensive experience across many private and public clinics in Germany — sharpened the analysis of the generational shift in Germany and prompted the fiscal-sustainability question presented in Section 4. The arguments here are mine. The responsibility for them is mine. Where I have been polemical, I have tried to mark it as such.
Acknowledgements. I thank Ms. Sophie Oder for the interview on 20 March 2026 in Zürich that prompted this essay and for her thoughtful questions on the structure and quality of private psychosomatic care in Germany. I am especially grateful to Mr. JK, a senior IT professional with extensive experience across many private and public clinics in Germany, whose written commentary on an earlier draft sharpened the analysis of the generational shift presented in Section 4 and contributed materially to the fiscal-sustainability argument that follows from it. I thank the clinical, research, and management teams at both Verus clinics — and my colleagues and students at Singularity Academy — for years of conversation that shape every page of what is written here. I also thank the international university partners with whom we collaborate.
Competing interests. YZ is the owner of the Verus Care Group and the president of Singularity Academy. The arguments advanced in this essay reflect that institutional position. YZ has not received external payment for writing this essay. No other competing interests are declared.
Funding. No external funding was received for the writing of this essay. All time and resources used in its preparation were contributed by the author and by Singularity Academy.
Ethics statement. No patient data, identifying clinical material, or unpublished primary research data are reported in this essay. All cited empirical claims are drawn from the published academic and policy literature listed in the References.
Data and materials availability. No new datasets were generated for this essay. All cited sources are publicly available and listed in the References. Correspondence regarding the arguments advanced here is welcome at the email address above.
How to cite this article: Zhang, Y. (2026). The system that eats itself: From Wirtschaftswunder to Wartezimmer — A personal view of the German mental health care sector. Singularity Academy Frontier Review, 2026(No. 05·26), Article SAFR 20260526. DOI: https://zenodo.org/records/20398185
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