Climatotherapy (Dead Sea and alpine cures)

1. Introduction

Version followed: climatotherapy as three provider systems publish it: (a) Dead Sea climatotherapy for psoriasis as Harari (2024) reviews it; (b) alpine high-altitude clinic treatment in Davos for atopic dermatitis and asthma as the Dutch DAVOS trial group, the Dutch Asthma Centre Davos cohort and the 2015 Dutch eczema guideline describe it; (c) German climate cures in state-recognised Heilklimatische Kurorte and North Sea / Baltic Sea resorts as the Deutscher Heilbäderverband (DHV), the Deutscher Tourismusverband and the Bavarian Interior Ministry publish them. German passages are paraphrased and marked (translated).

What it is. Climatotherapy is a medically prescribed stay in a place whose outdoor climate is used as the treatment. The DHV defines it by setting (translated): high mountains above about 1200 m, low mountain ranges (200–1000 m) and the sea coast. For the high mountains it names allergen poverty, increased UV and the altitude stimulus. For low mountains it names terrain paths and a gentle climate (Schonklima). For the coast it names a cold stimulus, sea aerosol, allergen freedom and UV [source: DHV brochure, Raschke chapter]. A consumer medical encyclopaedia describes the outdoor climate (cold, warmth, wind, sunlight, the water and salt content of the air) as repeated stimuli to treat disease, and calls the high mountains an "intensives Reizklima" (intense stimulus climate) with very few allergens [source: apotheken.de]. At the Dead Sea, the benefit is attributed to "the unique climatic factors of the region, essentially the sun and the sea" [source: Harari 2024]. Bathing in Dead Sea water and mud belongs to the next-door entry: see 180 Dead Sea balneotherapy.

How change is said to happen. The providers propose several routes: physical removal from home allergens, pollutants and triggers (house-dust mite and pollen poverty at altitude); natural UV exposure for inflammatory skin disease; adaptation to repeated climatic stimuli; and, as several sources say outright, the clinic setting itself. The Dutch guideline states that the mechanisms are not fully defined and that the setting, not only the altitude, may explain results. It names lower stress, better treatment adherence and contact with fellow patients [source: Richtlijn Constitutioneel Eczeem]. The Davos asthma authors add better air quality, better adherence and "removal from home or workplace stress" [source: Hashimoto et al. 2018]. For a psychotherapist this matters. Some of the change is psychosocial, and it is the part most likely to be lost on return home.

What climatotherapy is not. It is not a psychotherapy, and psychotherapists do not deliver it. Spa or cure physicians (Kurarzt, Badearzt) prescribe and supervise it, and dermatologists and pulmonologists run the clinics. Climate therapists, physiotherapists, nurses and movement therapists deliver the activities [source: Begriffsbestimmungen; Bavarian Merkblatt; Fieten 2018 slides]. It is not presented here as a treatment for any physical disease beyond the attributed claims and evidence below. This guide gives no sun, cold, altitude or walking schedules. Those are set individually by the supervising physician.

Evidence status (summary).

• Dead Sea psoriasis: a 2024 review of 26 studies (1982–2021) reports large short-term improvement. Length of stay and medical supervision "positively influenced the major outcomes". How long remission lasts and the long-term side effects "still need to be more precisely determined" [source: Harari 2024].
• Alpine treatment for atopic dermatitis in children (DAVOS trial): this pragmatic, open RCT randomised 84 children aged 8–18. A six-week multidisciplinary programme in the Davos alpine clinic was compared with the same type of programme as outpatient care in the Netherlands. At 6 weeks the alpine group improved more in disease activity and quality of life. At 6 months there was no significant difference, apart from a borderline difference on a catastrophising subscale. The authors concluded there was short-term benefit but no additional long-term benefit [source: Fieten et al. 2018, UMC Utrecht record].
• Alpine treatment for adult severe asthma: this was an uncontrolled cohort of 136 adults at the Dutch Asthma Centre Davos (1600 m). Quality of life and lung function improved after 12 weeks, and oral-steroid use fell. There was no control group and no long-term follow-up [source: Hashimoto et al. 2018].
• Dutch eczema guideline (NVDV, 2015): it found 11 observational studies, with relapse in most within about 3 months of return. The evidence was rated low. High-altitude treatment was given "no current place" pending ongoing research [source: Richtlijn Constitutioneel Eczeem].
• German spa association view: the DHV places the climatotherapy literature at Oxford level 2b, partly 3. It calls RCTs "nahezu unmöglich" (nearly impossible) for this treatment (translated) and notes missing control groups and follow-up [source: DHV brochure]. The LMU Munich resort-medicine chair describes long-term benefits for atopic, skin and respiratory disease. It also lists seasonal mood problems among uses, without study detail [source: LMU IBE page] [uncertain: not verified].

2. Framework

Climatotherapy is a residential programme delivered by others, not a staged psychotherapy. The phases below combine the published structure of the cure (middle column) with the psychotherapist's tasks around it. The psychotherapist's phases are [synthesis].

Criteria for moving on [synthesis]:

• 0→1: physician acceptance and medical clearance in writing, and the client's informed choice.
• 1→2: practical plan in place (care for children or dependants, school or work, finances), a named contact at the clinic, and a crisis plan if mental-health risk exists.
• 2→3: the date of return. Book the first session within the first week home.
• End of 3: the client has a written flare plan and maintenance routine, and mood and functioning are back to baseline or better.

Where it happens and how places are certified.

• Germany, state-recognised status: the title Heilklimatischer Kurort is a state award (Prädikat) under each Land's spa-resort law. The joint DHV/DTV Begriffsbestimmungen – Qualitätsstandards für die Prädikatisierung von Kurorten, Erholungsorten und Heilbrunnen (14th edition, foreword April 2024) set the national standards [source: Begriffsbestimmungen]:
  • a bioclimatic assessment or report, in simplified, standard or extended form;
  • air-quality assessment against resort reference values;
  • climate re-checked every ten years, and resort status reviewed every ten years;
  • at least one cure or spa physician familiar with the local remedies available throughout a stay.
• Germany, sea resorts: the 2011 revision separated Seebäder listed in the federal spa register from purely touristic ones, "mit und ohne kurortmedizinischen Hintergrund" (with and without a spa-medicine background) (translated). The 2023 revision added the See- und Thalassoheilbad [source: Begriffsbestimmungen].
• Bavaria (Merkblatt 04/2017): the ministry decides on recognition after a vote by an independent expert committee, usually with an on-site inspection [source: Bavarian Merkblatt]. Recognition requires (translated):
  • a current bioclimate analysis (e.g. from the Deutscher Wetterdienst);
  • an air-pollution report no older than five years;
  • a medical-climatological assessment of indications (e.g. from LMU Munich's resort-medicine institute);
  • proof that the climate has already worked as a remedy: physician-prescribed, supervised, documented climate cures must already take place on a substantial scale;
  • a Kurarzt and staff trained in the climate-cure concept, such as a climate therapist;
  • psychologische Betreuung (psychological support), which need not be given by psychotherapists;
  • at least three measured terrain-cure paths graded light, medium and heavy;
  • a climate-therapy centre, such as a rest hall or climate pavilion.
• Association label: the Verband der Heilklimatischen Kurorte Deutschlands awards an additional "Premium Class" label after on-site review. One Black Forest resort held it since 2003, was recertified in 2023 and is one of 15 such resorts [source: Baiersbronn press release]. This is a private association label, not the state award.
• Dead Sea and Davos: these are delivered in specialist clinics under dermatologists or pulmonologists. No equivalent certification standard was found for them [uncertain: not verified].
• North Sea and Baltic: the DHV lists sea climate for asthma, COPD, rhinitis, sinusitis and skin disease (incl. atopic dermatitis, psoriasis). Thalassotherapy, a complex therapy combining sea climate, sea water, mud and algae with exercise, increasingly adds mindfulness and meditation [source: DHV brochure]. The LMU page names North Sea and Baltic rehabilitation, including mother-father-child cures in specialised clinics [source: LMU IBE].

3. Guiding principles

• Medical lead stays medical. The cure or clinic physician decides indication, dose and stopping. You never suggest sun, cold, altitude or exertion levels [source: Begriffsbestimmungen; Bavarian Merkblatt].
• Describe evidence honestly. Short-term benefit is documented. Lasting benefit is not established, and observational studies are not trials. Say this before the client invests money, time and hope [source: Fieten 2018; Richtlijn; Harari 2024].
• The setting is part of the treatment. Lower stress, routine, peer contact and adherence may carry much of the effect. The psychotherapist's job is to find out which parts can be taken home [source: Richtlijn; Hashimoto 2018] [synthesis for the clinical use].
• Plan the return from the start. Relapse is the expected course for many. Present it as information, not failure [source: Richtlijn] [synthesis].
• Never advise on medicines. Steroid tapering, photosensitising drugs and asthma medication are for the prescriber. Route every question [synthesis, consistent with notes on heat and cold safety].
• Respect bodies and visibility. Treatments in the sun and on the beach expose skin that clients may hide. Body image, modesty and trauma need preparation, and consent applies to any practice that involves undressing [synthesis].
• Attribute claims. "Healing climate", "Reizklima" and "hardening" are provider concepts. Present them as what the resort or physician says, not as fact [source: apotheken.de; DHV brochure].
• Children need safeguarding. For paediatric programmes, the parent consents and the child gives assent. Separation, schooling and peer issues come into play, and so do safeguarding standards in residential care [synthesis].
• Stay in role. A psychotherapist may support, prepare and integrate. You do not lead walks, sun or sea exposures as treatment unless you are separately trained and employed for that by the facility [synthesis].

4. Intervention inventory

Part A describes the climatic treatments as their providers publish them. These are delivered by physicians and their teams, and nothing in Part A is an instruction for a psychotherapist to carry out. Part B covers the psychotherapist's own work around a cure. Part C is the safety screen used throughout.

Part C first: cautions and safety screening

What the sources state:

• Sun damage (Dead Sea): a controlled cross-sectional study compared 460 psoriasis patients treated at the Dead Sea with 738 controls. The patients had more solar damage (elastosis, lentigines, poikiloderma, wrinkles), rising with total Dead Sea exposure. Melanoma and non-melanoma skin cancer were not increased [source: David et al. 2005].
• Long-term side effects of Dead Sea treatment: these "still need to be more precisely determined" [source: Harari 2024].
• DAVOS trial: five serious adverse events occurred, none judged treatment-related [source: Fieten et al. 2018].
• Mid-mountain climate: the DHV brochure gives no climate-specific contraindications. For mid-mountain climatotherapy it states there are "keine Gegenindikationen" (no contraindications) (translated) [source: DHV brochure]. That is the provider's claim, not an independent safety review.

Cautions to clear with the physician [synthesis; these were not found as a published list for climatotherapy] [uncertain: not verified]:

• Sun: history of skin cancer or many atypical naevi; photosensitive conditions; photosensitising medicines; very fair skin. All are for the dermatologist and prescriber.
• Altitude: severe heart or lung disease, pulmonary hypertension, recent cardiac events, pregnancy, sickle-cell disease. All are for the cure physician.
• Cold, wind and sea climate: cardiovascular disease, Raynaud's, cold-induced asthma. Sea bathing brings cold shock and drowning risk. This is the same safety territory as cold-water practices in this family, and open-water swimming as a nature practice cross-refers to Domain XV.
• Heat and dehydration: relevant in hot climates such as the Dead Sea region, especially for older adults, people on diuretics, lithium, anticholinergics or antipsychotics, and anyone using alcohol.
• Exertion on terrain paths: cardiac and orthopaedic limits are set by the physician, and paths are graded for this reason [source for grading: Bavarian Merkblatt].
• Mental-health risks:
  • active suicidality, mania or psychosis, or severe eating disorder: residential distance from usual care can matter;
  • substance use;
  • severe separation anxiety in children;
  • trauma linked to institutional stays.

Screening routine [synthesis]:

1. The client asks the treating physician whether climatotherapy is indicated.
2. The cure or clinic physician does the medical screening.
3. You screen the mental-health items above, plus current treatment, a crisis plan and the support available at the destination.
4. You never advise on medicines and route every medicine question to the prescriber.

Part A: climatic treatments as published

A1. Dead Sea climatotherapy (sun and sea)

• Purpose / when used: symptom control in psoriasis. This is the indication reviewed in Harari (2024). The benefit is attributed to sun and sea in the region [source: Harari 2024]. The physical mechanisms given in the wider literature were not confirmed in the sources used here [uncertain: not verified].
• What is published:
  • a stay of several weeks in the Dead Sea region;
  • sun exposure and sea bathing under medical supervision (the details of how exposure is graded were not verified) [uncertain: not verified];
  • longer stays and medical supervision associated with better outcomes [source: Harari 2024].
• Not given here: exposure times or sequences.
• Related entry: bathing in the hypersaline water and mud as balneotherapy is covered in 180 Dead Sea balneotherapy.
• Example language (illustrative): "The published studies show that many people's skin clears a great deal during a supervised stay. They're less clear about how long it lasts. Shall we think about what you'd want from it and how you'd cope if it comes back?"
• Watch for:
  • sunburn or a rash reported during the stay: route it to the clinic dermatologist;
  • body-image distress around visible skin and swimwear;
  • disappointment on relapse;
  • financial strain, since cost and insurance coverage vary [uncertain: not verified].

A2. Alpine high-altitude clinic treatment (Davos)

• Purpose / when used: difficult-to-treat atopic dermatitis in children and adults, and severe asthma in adults. It is offered by Dutch-run clinics in Davos at about 1600 m [source: Fieten 2018; Hashimoto 2018].
• What is published:
  • a personalised, multidisciplinary programme in a "low-trigger environment". The team includes physicians, a dermatology nurse and an allergist, with intensive topical treatment for AD [source: Fieten 2018 slides; Richtlijn; Hashimoto 2018];
  • the stated climate rationale: allergen poverty (no house-dust mite above about 1500 m, per apotheken.de), a dry cool climate and higher UV [source: Richtlijn; apotheken.de];
  • the setting itself, with less stress, more adherence and peer contact, named as a likely contributor [source: Richtlijn];
  • stays of 4–6 weeks for AD and around 12 weeks in the asthma cohort.
• Patient goals named for children with AD: less itch, better skin, sleep, keeping to the school schedule, mood [source: Fieten 2018 slides].
• Evidence: see section 1. The short-term RCT benefit over Dutch outpatient care was not sustained at 6 months [source: Fieten 2018]. The Dutch guideline (2015) gave it no current place pending research, and it was not covered by standard Dutch insurance at that time [source: Richtlijn].
• Example language (illustrative): "The trial found that children improved more in Davos than at home in the first weeks, but by six months the two groups were about the same. That's useful to know before deciding. It may help to think of the stay as a reset and a learning period rather than a cure."
• Watch for:
  • homesickness and missed school or work;
  • steroid reductions that worsen mood or sleep after return: route to the prescriber;
  • catastrophising about the disease, which was a measured outcome in DAVOS [source: Fieten 2018];
  • loss of peer support after return.

A3. Heilklima cure in a German Heilklimatischer Kurort (terrain cure, rest in the open air)

• Purpose / when used: the providers name prevention, rehabilitation and convalescence. For mid-mountain climate the DHV names internal and orthopaedic conditions, convalescence and follow-on rehabilitation (Anschlussheilverfahren) [source: DHV brochure]. The LMU resort-medicine chair also lists seasonal mood swings and lack of fitness [source: LMU IBE]. Treat these as provider claims with low to moderate evidence (DHV's own rating: level 2b–3) [source: DHV brochure].
• What is published:
  • a physician-prescribed, supervised and documented climate cure [source: Bavarian Merkblatt];
  • walking on a network of bioclimatically and physiologically measured terrain paths graded light, medium and heavy;
  • rest in a climate-therapy centre (rest hall, climate pavilion, meadows);
  • movement therapy, physiotherapy and sport therapy, relaxation rooms and nutrition programmes;
  • staff trained in the climate-cure concept ("Klimatherapeut") and psychological support (psychologische Betreuung) (translated) [source: Bavarian Merkblatt];
  • a German Kur in general lasting at least three weeks [source: Begriffsbestimmungen].
• Not given here: walking intensities, cooling or clothing protocols, durations.
• Example language (illustrative): "A climate cure in Germany is prescribed by a spa doctor, who decides how far and how hard you walk and how much you're outdoors. My part is to help you work out what you want from three weeks away and how to keep the good parts going when you come back."
• Watch for:
  • over-exertion driven by perfectionism or a wish to "earn" recovery;
  • pain flares;
  • low mood when the routine ends;
  • over-reading the label "Heilklima" as a guarantee.

A4. North Sea and Baltic Sea climate cures and thalassotherapy

• Purpose / when used: the DHV names asthma, COPD, rhinitis, sinusitis and skin disease (incl. atopic dermatitis, psoriasis) for sea climate. For thalassotherapy it adds functional orthopaedic and rheumatic conditions, fibromyalgia, sleep problems, exhaustion and long COVID [source: DHV brochure]. The LMU page names North Sea and Baltic rehabilitation, including mother-father-child cures in specialised clinics [source: LMU IBE].
• What is published:
  • climatic stimuli named as a cold stimulus, aerosol, allergen freedom, UV and wind [source: DHV brochure];
  • thalassotherapy as a complex therapy combining sea climate, sea water, mud and algae with exercise, and increasingly mindfulness and meditation [source: DHV brochure];
  • since 2023, the German standards include the See- und Thalassoheilbad as a distinct resort type, and thalassotherapy requires a site near the sea [source: Begriffsbestimmungen].
• Evidence (DHV's own rating): level 2b with some level 3 and single level 1 papers. It claims good evidence for skin disease, especially combined with UVB [source: DHV brochure]. This is an association's own summary.
• Example language (illustrative): "The sea-climate cures you've read about are run by spa doctors. If mindfulness or relaxation groups are part of the programme, we can link them to what we already practise here so you're not starting from scratch."
• Watch for:
  • cold exposure or sea bathing in clients with cardiac disease or alcohol use (cold shock, drowning): route to the physician;
  • parent exhaustion on mother-father-child cures;
  • children's distress in group settings.

A5. Related form: speleotherapy (salt mines and caves)

• What is published: the DHV calls cave or disused-mine stays "a special form of climatotherapy" and lists 12 therapy sites in Germany (translated). It cites level Ib evidence for asthma and found no significant improvement for long COVID [source: DHV brochure].
• For the psychotherapist: handle it as A1–A4: a physician's decision.
• Example language (illustrative): "That's a medical question for your lung specialist. Shall we write it down for your next appointment?"
• Watch for: claustrophobia or panic in enclosed underground settings, and expectations raised by marketing [synthesis].

Part B: the psychotherapist's interventions

Unless tagged otherwise, Part B is [synthesis]. It is built on what the sources say about the setting, relapse and outcomes: stress, adherence, peer contact, catastrophising and relapse within months [source: Richtlijn; Fieten 2018; Hashimoto 2018]. German resorts must also provide psychological support, which need not come from psychotherapists [source: Bavarian Merkblatt]. A client may therefore meet psychologists or counsellors on site, and you can coordinate with them.

B1. Recognising a possible fit and raising it

• Purpose / when: for clients with chronic atopic dermatitis, psoriasis or severe asthma whose illness drives distress, sleep loss, avoidance or work and school problems, and who are asking about options.
• Steps:
  1. Ask what the client already knows and has been told by their physician.
  2. Give neutral information: such cures exist, physicians prescribe them, and the evidence is mainly short-term.
  3. Suggest the client raise it with their dermatologist, pulmonologist or GP.
  4. Do not recommend a specific clinic.
• Example language (illustrative): "Some people with severe eczema go to supervised clinics in the mountains or at the Dead Sea. Whether that's medically right for you is a question for your dermatologist. Would you like to take it to them?"
• Watch for: magical hopes ("this will fix everything"); avoidance of local treatment while waiting for the cure; pressure from family or forums.

B2. Psychological suitability screen and crisis plan

• Purpose / when: before departure, to reduce risk from distance and disruption.
• Steps:
  1. Review current risk: suicidality, self-harm, mania or psychosis, eating disorder, substance use.
  2. Ask about earlier experiences of hospital, boarding school or institutional stays and how they felt.
  3. Agree a crisis plan that names the on-site physician, local emergency numbers and how to reach you.
  4. If risk is high, recommend postponing and say why. The medical decision remains with the physician.
• Example language (illustrative): "Being far from home for weeks can be hard even when it goes well. Let's write down what you'd do, and who you'd contact there, if your mood dropped badly."
• Watch for: reluctance to disclose risk for fear of losing the place; past institutional trauma reactivated by clinic routines.

B3. Informed-expectations conversation

• Purpose / when: once a stay is being considered, to prevent disappointment and support informed choice.
• Steps:
  1. Summarise the evidence in plain words: clear short-term gains, and frequent relapse within months of return [source: Richtlijn; Fieten 2018; Harari 2024].
  2. Ask what success would look like at 6 weeks and at 6 months.
  3. Separate goals the climate might affect (skin, airway symptoms) from goals the client can take home (sleep routine, adherence, activity, coping skills, self-compassion).
  4. Write the goals down for the post-return session.
• Example language (illustrative): "If your skin clears there and then flares a few months later, what would you want to have gained anyway?"
• Watch for: all-or-nothing goals; self-blame scripts prepared in advance ("if it comes back it's my fault").

B4. Practical and emotional preparation

• Purpose / when: in the weeks before leaving.
• Steps:
  1. Map practicalities: dependants, school or work arrangements, money, language and communication.
  2. Name expected feelings: homesickness, guilt about leaving family, relief, being among other patients.
  3. Plan small anchors: a contact routine with home, personal objects, journaling.
  4. For children: work through separation, schooling and the child's own questions with the parents.
• Example language (illustrative): "Many people feel two things at once before a stay like this, hope and dread. Which is louder for you right now?"
• Watch for: avoidance of planning; strong anticipatory anxiety; family conflict over the decision.

B5. Preparing for body exposure, visibility and touch

• Purpose / when: for treatments that involve exposing skin to sun or sea, being in swimwear among others, and clinical skin examination or application of creams by staff.
• Steps:
  1. Ask how the client feels about others seeing their skin and body.
  2. Explore trauma history, religious modesty, gender identity and body-image concerns.
  3. Rehearse asking staff for privacy, a same-gender clinician or a chaperone, and the right to decline or stop any procedure.
  4. Remind the client that clinical touch is by consent, and that sexual touch never belongs in treatment.
  5. Agree how they will tell you and the clinic if something felt wrong.
• Example language (illustrative): "You can always ask for a pause, a different staff member, or for someone else to be present. Would it help to practise how you'd say that?"
• Watch for: shame-driven withdrawal from treatment sessions; dissociation during examination; reports of boundary violations. Take these seriously and follow your reporting duties.

B6. Consent to share information and collaboration

• Purpose / when: whenever psychological care should be coordinated with the clinic physician or on-site psychological staff.
• Steps:
  1. Get written consent stating exactly what may be shared, with whom and for how long.
  2. Send a brief summary of relevant mental-health information and the crisis plan.
  3. Agree how adverse effects or concerns will be passed in each direction.
  4. Never give advice on medicines, sun, cold or exercise. Route all of it to the physician or prescriber.
• Example language (illustrative): "With your permission I'd send the clinic a short note about your anxiety and our crisis plan, and nothing else. What would you want left out?"
• Watch for: splitting between teams; the client relaying conflicting advice; gaps when the client returns home.

B7. Support during the stay (optional)

• Purpose / when: for clients with significant distress who want continuity. Only if the clinic agrees, and only where your licence allows remote work across the border.
• Steps:
  1. Agree in advance on the frequency of contact and the channel.
  2. Keep sessions focused on coping and on noticing what helps.
  3. Do not discuss or adjust the climatic treatment itself.
• Example language (illustrative): "What's one thing about the days there that seems to help, apart from the climate itself?"
• Watch for: exhaustion from the programme; group dynamics with other patients; mood dips as the end approaches.

B8. Working with illness cognitions, catastrophising and itch-related distress

• Purpose / when: before, during and after a stay. Catastrophising was one of the DAVOS trial's measured outcomes, and the borderline 6-month difference favoured the alpine group [source: Fieten 2018]. The coping techniques themselves are [synthesis], drawn from general CBT practice and not from the climatotherapy sources.
• Steps:
  1. Identify catastrophic predictions about flares and relapse.
  2. Gather evidence from the stay: which symptoms changed, and what the client did differently.
  3. Build balanced statements and a flare plan agreed with the physician.
  4. Use behavioural experiments to test avoidance, for example of social contact during a flare.
• Example language (illustrative): "When the first patch came back, what did your mind tell you it meant? What else could it mean?"
• Watch for: a shift from "it's cured" to "nothing works"; avoidance returning; sleep loss.

B9. Return transition and relapse planning

• Purpose / when: in the first weeks home, the period in which the sources report most relapse [source: Richtlijn; Fieten 2018].
• Steps:
  1. Book a session within the first week home.
  2. Review the goals written in B3 against what actually happened.
  3. List which elements can travel home: daily routine, treatment adherence, activity outdoors (within medical advice), rest, peer contact by patient groups or online.
  4. Write a flare plan: early signs, the physician's treatment steps, coping steps, who to contact.
  5. Normalise the dip in mood after a structured stay ends.
• Example language (illustrative): "Coming back from weeks of structure to ordinary life is a drop for almost everyone. Let's pick the two or three things from there that you most want to keep."
• Watch for: grief or anger at relapse; self-blame; requests to repeat the stay as the only option; changes in medication by the physician after return that affect mood or sleep (route questions to the prescriber).

B10. Integrating the experience: activation, nature and connection

• Purpose / when: after the stay, to turn a time-limited experience into lasting behaviour.
• Steps:
  1. Ask what was meaningful: landscape, people, rest, feeling competent in their body.
  2. Translate it into behavioural-activation goals at home, such as regular walks in green or blue space, social contact or a relaxation practice learned there. Any intensity or exposure is set with the physician.
  3. Schedule these goals, review them and adjust.
  4. For outdoor water activities, open-water swimming as a nature practice is covered in Domain XV.
• Example language (illustrative): "You said the walks felt like the first time in years you weren't thinking about your skin. What would a small home version look like?"
• Watch for: idealising the resort; loss of motivation without structure; seasonal mood change. Claims about climate and seasonal mood come from the providers and are not verified as treatment evidence [uncertain: not verified].

B11. Recognising and passing on adverse effects

• Purpose / when: throughout, for any physical or psychological reaction during or after the stay.
• Steps:
  1. Ask about it routinely.
  2. For physical signs, advise the client to contact the clinic or their physician promptly. Examples: sunburn, new or changing skin lesions [source for solar damage: David et al. 2005], breathing problems, chest pain, fainting, cold injury, heat exhaustion.
  3. For psychological reactions (low mood, panic, resurfacing trauma, disordered eating), assess and treat within your own role and inform the clinic with consent.
  4. Document what was reported and to whom.
• Example language (illustrative): "That sounds like something the clinic doctor needs to hear today. Can you call them now? I'll make a note that we've spoken about it."
• Watch for: minimisation ("it's just part of the cure"). Provider concepts such as an initial reaction to the Reizklima should never be used to explain away symptoms that need medical review.

B12. Children, adolescents and family cures

• Purpose / when: paediatric altitude programmes (DAVOS: ages 8–18) and North Sea or Baltic mother-father-child cures [source: Fieten 2018; LMU IBE].
• Steps:
  1. Obtain parental consent and the child's own assent, in age-appropriate words.
  2. Work with parents on separation, school continuity and peer issues.
  3. Check that the clinic has safeguarding arrangements for residential care. Your own safeguarding duties remain in force.
  4. After return, watch school reintegration and stigma about skin or asthma.
• Example language (illustrative), with a child: "What would you like to be different when you come back? And what are you worried about?"
• Watch for: distress the child does not report to parents; regression; bullying on return; parental guilt or exhaustion.

5. Handling problems

The climatotherapy sources do not address psychotherapy problems directly. All guidance below is [synthesis] unless a source is given.

• Relapse after return (the most common problem).
  • What sources say: relapse within about 3 months in most altitude studies [source: Richtlijn]. DAVOS gains were not sustained at 6 months [source: Fieten 2018]. Dead Sea remission length is undetermined [source: Harari 2024].
  • Response: return to the B3 goals, separate symptom relapse from personal failure, and strengthen the skills that carried over. Ask the physician about the next medical steps. Do not frame a repeat stay as the only hope.
• The client wants to go against medical advice, or to self-organise a "cure" holiday.
  • Why it matters: unsupervised sun and sea exposure carries the solar-damage risk the Dead Sea study measured [source: David et al. 2005], and medical supervision was linked to better outcomes [source: Harari 2024].
  • Response: explore the motive (hope, frustration with local care) and encourage a physician review. Do not give exposure advice.
• Stuck: "nothing works" after a failed stay.
  • Response: validate the disappointment, then review what did change, even briefly. Work on catastrophising (B8), and consider referral for psychodermatology or specialist asthma psychology where available.
• Over-exertion or perfectionism during the cure.
  • Response: name the pattern. Remind the client that the physician sets intensity and that graded paths exist for this reason [source: Bavarian Merkblatt]. Help them tell staff honestly how they are.
• Overwhelm or acute distress on site.
  • Response: use the crisis plan (B2) and involve on-site physicians or psychological staff. The Bavarian standards require psychologische Betreuung at Heilklimatische Kurorte [source: Bavarian Merkblatt]. If risk is acute, the local emergency services take precedence over remote sessions.
• Non-adherence to the home routine after return.
  • Response: shrink the goals, link them to existing habits, use activity scheduling, and review weekly. Ask whether medication or skin-care routines feel burdensome and route those questions to the prescriber.
• Rupture: the client feels you discouraged or over-sold the cure.
  • Response: acknowledge it. Restate that the decision belonged to the client and the physician. Return to the client's own goals.
• Body exposure distress, or a reported boundary violation.
  • Response: for distress, see B5. For any report of inappropriate or sexual touch by staff, take it seriously, support the client, document it, and follow your reporting and safeguarding duties. The client may complain to the clinic and to the relevant professional or regulatory body.
• Family conflict over cost or absence.
  • Response: hold a joint session if useful. Be clear about the uncertain long-term benefit. Cost and insurance coverage vary by country and over time, so the client should check with the payer [source for the Dutch position in 2015: Richtlijn] [uncertain: not verified for other countries].
• Children who refuse or struggle.
  • Response: the child's assent matters. Explore the fears, involve the parents and the clinic team, and accept that a stay may not suit this child now (B12).
• Belief claims ("the healing climate will detox me").
  • Response: attribute such concepts to the resort or tradition. The sources used here describe allergen avoidance, UV and the clinic setting, not detoxification [source: DHV brochure; apotheken.de].
• Medicine and medical questions.
  • Response: never advise on steroid tapering, photosensitising drugs or inhalers. Route every such question to the prescriber or clinic physician.

Sources

Pages used:

• Harari M. Psoriasis treatment at the Dead Sea: 40 years of clinical studies. IMAJ 2024;26(3):196–201
• Deutscher Heilbäderverband / Deutscher Tourismusverband: Begriffsbestimmungen – Qualitätsstandards für die Prädikatisierung von Kurorten, Erholungsorten und Heilbrunnen, 14th ed. (hosted by RP Kassel)
• Deutscher Heilbäderverband: Evidenz der natürlichen ortsgebundenen Heilmittel in staatlich geprüften, prädikatisierten Heilbädern und Kurorten, 1st ed. (climatotherapy and thalassotherapy chapters by F. Raschke)
• NVDV, Richtlijn Constitutioneel Eczeem: De effectiviteit van hooggebergtebehandeling bij CE (2015)
• Fieten K et al. Effectiveness of alpine climate treatment for children with difficult to treat atopic dermatitis: results of a pragmatic randomized controlled trial (DAVOS trial). Clin Exp Allergy 2018;48(2):186–195 (UMC Utrecht record)
• Fieten K. Alpine climate treatment for children with difficult to treat AD (slides, Graubünden forscht 2018)
• Hashimoto S, Rijssenbeek-Nouwens LH, Fieten KB, Weersink EJ, Bel EH. Predictors of benefit from high-altitude climate therapy in adults with severe asthma. Neth J Med 2018;76(5):218–225
• David M et al. Actinic damage among patients with psoriasis treated by climatotherapy at the Dead Sea. J Am Acad Dermatol 2005;52(3):445–450
• Bayerisches Staatsministerium des Innern: Merkblatt Anerkennung als Heilklimatischer Kurort (04/2017)
• Baiersbronn: press release on recertification of Obertal-Buhlbach as Heilklimatischer Kurort der Premium Class (2023)
• LMU Munich, Chair for Public Health and Health Services Research: Climatotherapy
• Schäffler A, Machotta T. Klimatherapie. apotheken.de (updated 2024)

Cited in the DHV brochure, full text not verified [uncertain: not verified]:

• Fieten et al. (2014), systematic review of alpine climate treatment for atopic dermatitis.
• Schuh & Nowak (2011), Dtsch Med Wochenschr, on climatotherapy in the high mountains and sea climate.
• Vinnikov et al. (2016), systematic review and meta-analysis of high-altitude climate and lung function in asthma.
• Wahl et al. (2015), Acta Derm Venereol, on psoriasis self-management and severity after climatotherapy.

Related entries: 180 Dead Sea balneotherapy; open-water swimming as a nature practice: Domain XV.