How can caring for mentally ill refugees succeed in the long term?
BPtK Round Table of Expert Practitioners in Germany, 16 February, 2017
Since early 2014, over 1.5 million refugee have sought refuge in Germany. A large proportion of them experienced traumatic events prior to their arrival. Many of them are traumatised, psychologically burdened or ill, and need help. Yet, the health care that they receive is far from complete. In particular, the limitations contained in Germany’s Asylum Seekers Benefits Act and the lack of funding for language mediators dramatically hamper the task of providing refugees with adequate health care.
Over the past two years, solutions for helping refugees better have emerged from numerous initiatives. The Federal Chamber of Psychotherapists (BPtK) therefore invited the representatives of such initiatives to a round-table meeting in Berlin on 16 February, 2017. The aim of the meeting was to exchange ideas and opinions about which approaches to caring for mentally stressed and ill refugees are helpful; about existing challenges and obstacles to implementation; and about how the projects can be sustained to ensure the long-term care of mentally ill refugees.
Psychosocial primary care for refugees
Refugio München holds psycho-educative discussion groups for refugees living in reception facilities. The refugees are informed about psychological conditions, and provided with strategies for coping with these conditions in the living circumstances of the reception facility. These consultations are focused on identifying those refugees who are under acute stress, so that Refugio München can provide them with treatment.
The recently established Survival Centre (Zentrum Überleben) in Berlin offers a programme for treating refugees suffering from acute mental illness. Refugees receive weekly consultations for a period of six months. The centre’s multi-disciplinary team of psychotherapists, psychiatrists and social workers conducts emergency psychological interventions, clinical social work and psychiatric treatment. The team’s practical experience has shown that focussing on psychotherapy alone during the initial stage of arrival in Germany is insufficient. It has found that psychotherapy specifically focussed on treatment trauma is only feasible once patients have gained a degree of stability both vis-à-vis the new environment and within themselves.
In addition to providing psychotherapeutic treatment, the Interpersonal, Integrative Pilot Project for Refugees with Mental Disorders (Interpersonelles integratives Modellprojekt für Flüchtlinge mit psychischen Störungen) is particularly focussed on integrating mentally ill refugees into work and social environments. For this purpose, interpersonal psychotherapy, which was originally developed for the treatment of depression, has been adapted to treating refugees. The therapy consists of ten sessions focussing on sadness, loneliness, interpersonal role changes and conflicts, and integration. The programme was developed at the University of Marburg and is funded by the Federal Ministry of Labor and Social Affairs.
An interactive concept that employs short videos, picture stories and worksheets has been specially developed for refugee children, including the very young. The child-friendly and culture-sensitive materials inform the children about various types of traumatic experiences and their potential effects. This enables them to understand better what they or others have experienced. Children are particularly vulnerable to developing mental illnesses as a result of traumatic experiences. The materials are intended for social workers, preschool teachers and teachers; however, financing for the programme has yet to be found.
The START programme is designed for refugee children and adolescents. For many of them, beginning a long course of psychotherapy upon arrival in Germany is impossible. START is therefore primarily aimed at rapid stabilisation and stress reduction. The programme then focusses on promoting self-care and mindfulness, and strengthening protective factors. Its manual has been translated into various languages to allow low-threshold, culturally integrative access. Multilingual audio versions are also available, thus enabling most of the programme to be conducted without interpreters, and with groups of children and adolescents who speak different languages. The concept is also designed in a manner that allows it to be offered to preschool teachers, teachers and social workers.
HOPE is a project of the Psychosocial Centre (Psychosoziales Zentrum) of the German Red Cross (DRK) aimed at orienting and psycho-educating traumatised refugees, in particular those who are unaccompanied minors. It offers them psychological support in coping with traumatic experiences, and helps them integrate into and adapt to German culture. When necessary, a co-ordination centre of the DRK also refers the refugees to psychotherapists, physicians and specialised clinics.
Not all refugees in Germany who need psychosocial or psychotherapeutic treatment are able to get prompt face-to-face help. Moreover, those still living in crisis zones and war zones or in refugee camps often have no means of obtaining psychosocial or psychotherapeutic assistance. In all of these cases, web-based services can provide an alternative.
The Survival Centre in Berlin has therefore developed e-mail-based therapies in Arabic for trauma and depression, which are particularly intended for people living in war zones. Following a detailed diagnostic examination by telephone, the patients are admitted into a short-term therapy programme conducted by e-mail. These therapy programmes, however, must often be discontinued, due to the dangerous circumstances in which the patients are living. The centre has also developed a self-help app in Arabic for people with mild depressive conditions.
The Refugeum website is a self-help tool that went online in September 2016, and is currently available in seven different languages. It provides information about mental disorders, as well as guidance for self-help in coping with sadness, anxiety, sleep-related issues and stressful memories. It also explains strategies for activating one’s personal sources of strength, for helping oneself by keeping a diary, and for getting a good night’s sleep. To date, over 3,000 people from 34 countries have visited the website. There are plans to translate the website into more languages, as well as to make it accessible to refugees unable to read through the use of images and videos. The website has been set up without financial support by psychology students and other volunteers.
Training and employing lay assistants
In2Balance – Lay Assistance for Refugees toward Psychological Stabilisation (Laienhilfe für Flüchtlinge zur psychischen Stabilisierung) is a pilot prevention project conducted by the Psychosocial Centre (Psychosoziales Zentrum) in Dusseldorf, and funded by the health ministry of North Rhine-Westphalia. The project currently has 18 lay assistants working in eight refugee shelters in Dusseldorf. All of them receive training and continuous professional support. In2Balance is intended to help reduce the psychological stress suffered by refugees and prevent subsequent illnesses. Those refugees who the lay assistants believe to require treatment are referred to psychotherapists and physicians for diagnosis. It is often, however, difficult to refer them into the regular psychotherapeutic care system, particularly in rural regions.
The Gewiss e.V. Society has developed a model for providing trained lay assistance that is supported by psychotherapists and physicians involved in trauma therapy. Lay assistants are trained in the principles of psychotraumatology and neurophysiology, stabilisation and self-calming techniques, and in therapeutic concepts for traumatised refugees. The training is primarily intended for preschool teachers, teachers and social pedagogues involved in refugee relief who can apply it to their daily work. In3Balance also trains laypersons to assist professionally led group therapy programmes for refugee children and adolescents.
Low-threshold psychosocial primary care does not sufficiently meet the needs of all traumatised and mentally ill refugees. Some require long-term psychotherapy. The long waiting periods to receive such therapy, however, demonstrate that existing psychotherapeutic capacity in Germany is not adequate to fulfil the added task of treating mentally ill refugees in a timely manner. In September 2014, German legislators therefore created a provision authorising private psychotherapeutic practices and psychosocial centres to treat refugees, and thus provide them with outpatient care.
This provision, by which mentally ill refugees may also be treated by specially authorised practices is, however, practically useless. Indeed, the practices of some psychotherapists authorised by the provision lack any patients. The category of refugees eligible to receive treatment under the authorisation provision is so severely restricted that, in many places, no patients whatsoever are eligible. In fact, the provision is so complicated that it is sometimes practically impossible to determine whether a refugee falls within the category in which he or she may be treated by authorised practitioners. Moreover, therapies already underway must be terminated whenever the patient’s legal status changes.
A collaboration between the out-patient psychotherapy unit of the Braunschweig University of Technology, the state refugee reception centre in Braunschweig and the City of Braunschweig demonstrates how providing health care to refugees can be improved through better coordination on the ground. Social workers and physicians at the reception centre advise refugees to seek counselling at the out-patient psychotherapy unit. There they undergo a thorough diagnostic examination funded by the state reception centre and the City of Braunschweig. If an indication for treatment arises, the cost of exploratory sessions and 18 hours of psychotherapy is also covered. Interpreters are on hand for both diagnostic and therapeutic sessions.
Co-ordinating and networking support staff
Germany’s statutory regulations governing the care of mentally ill refugees are complicated and difficult to decipher. It is not always clear who may perform what, and who is to bear the associated costs. The process of applying for therapy is complex, which in turn makes it difficult to refer refugees into the regular psychotherapeutic care system. Co-ordinating bodies, however, can be helpful.
The Coordination Centre for the Interculturally Opening the Health Care System and Improving the Treatment of Mentally Ill Refugees (Koordinierungsstelle für die interkulturelle Öffnung des Gesundheitswesens und Verbesserung der Behandlung von psychisch kranken Flüchtlingen) in Rhineland offers training in the care of mentally ill refugees to psychotherapists and physicians. The co-ordination centre is also in the process of establishing a network of psychotherapists, as well as a pool of language mediators. If they so request, refugees are referred to trained psychotherapists. The co-ordination centre also helps with questions related to applying for services and the invoicing of services.
The Lower Saxony Network for Traumatised Refugees (Netzwerk für traumatisierte Flüchtlinge Niedersachsen) refers refugees into the regular psychotherapeutic care system. When requests for psychotherapy are submitted, the network’s full-time staff search for a suitable psychotherapist and an appropriate interpreter. The network also applies for coverage of the costs of psychotherapy and language interpretation, and, when necessary, assists the therapists with legal matters concerning foreigners and with producing patient reports.
The Refuge Working Group (Arbeitskreis Asyl) in Münster is demonstrating how refugees can be transferred into the regular health care system better. It has compiled a database of psychotherapists offering treatment to refugees, and meets regularly to discuss technical matters and administrative issues concerning the treatment of mentally ill refugees. The Refuge Working Group is a collaborative project between Refugio Münster and the psychotherapeutic network of Münster and the Münster region.
Use of interpreters and language mediators
Psychotherapy is impossible without a sufficient degree of mutual linguistic understanding. Employing specially qualified interpreters, along with language mediators and integration facilitators, is therefore usually an indispensable element of providing psychotherapy to refugees. Social services, however, rarely finance their services; and the statutory health insurance authority refuses categorically to assume these costs.
In Hamburg, a 200,000-euro fund has been set up to cover the interpreter costs associated with providing psychotherapeutic care to refugees. Approved by the Hamburg state parliament, the fund stems from a joint initiative of the Association for Mental Health, Migrants and Refugees (Verein für Seelische Gesundheit, Migration und Flucht (SEGEMI)), the Hamburg Chamber of Psychotherapists, the Welfare Parity Organisation (Paritätischer Wohlfahrtsverband), and local politicians. Established psychotherapists will now be able to apply to the fund for interpreter funding. The interpreters receive prior training, and are supervised during the course of therapy.
The Between Languages project (ZwischenSprachen) establishes standards of quality for the purpose of qualifying language mediators for social work with refugees. Previous qualification courses were very heterogeneous, which had made it practically impossible to assess the competencies of interpreters and language mediators. Hence, the project’s aim is to develop a standard curriculum and learning objectives for language mediators working in social services, which can be used as a blueprint for the mandatory training of language mediators in the psychotherapeutic field. Actively involved in the project are the University Medical Center Hamburg-Eppendorf, the International Association for Education, Culture and Participation (Internationale Gesellschaft für Bildung, Kultur, Partizipation), and the Diakonie Hamburg, the city’s Protestant social services society.
The Federal Association of Interpreters and Translators (Bundesverband der Dolmetscher und Übersetzer), together with SEGEMI, has developed a three-day course to qualify interpreters for psychotherapeutic work.
Since 2010, the Language Mediator Pool of North Rhine-Westphalia (Sprachmittlerpool NRW) has been placing specially qualified language mediators and integration facilitators for over 90 languages and dialects. The professional development course for language mediators and integration facilitators consists of training sessions in the fields of education, social issues and health, and includes a high degree of psychological, psychotherapeutic and psychiatric content. The language mediators and integration facilitators are able to explain socio-cultural differences, and are placed, for example, in the Rhineland Regional Council’s medical centres, with which close collaboration exists. The Language Mediator Pool of North Rhine-Westphalia is sponsored by the International Association for Education, Culture and Participation in Cologne.
Calls on policymakers
- Permanent funding required: For most of the projects presented at the round-table meeting in Berlin, long-term financing has yet to be secured. Project funding is only allocated for fixed periods, and must be reapplied for repeatedly. During the meeting, the criticism was made that the responsibility of caring for mentally ill refugees is not being adequately accepted by policymakers.
- Multi-disciplinary care necessary: The progress reports presented at the meeting make it clear that refugees require multi-disciplinary support, particularly at the beginning of their stay in Germany. In the opinion of those present, an exclusive focus on psychotherapy is insufficient. The view was that providing adequate health care to refugees requires a collaborative approach by psychotherapists, social workers and psychiatrists. Yet, the Asylum Seekers Benefits Act (Asylbewerberleistungsgesetz) does not provide a legal framework for fundamentally ensuring that a multi-disciplinary package of psychosocial assistance is available to every refugee. Primary psychosocial care for every mentally ill refugee should be financed by Germany’s department of public welfare (Sozialamt).
- A failed authorisation process: Reports presented at the meeting by authorised psychotherapists and psychosocial centres clearly indicated that the statutory provision enabling psychotherapists and psychosocial centres to be specially authorised to treat mentally ill refugees has failed. Indeed, the number of refugees who may be treated based on such authorisation is so extremely restricted that in many places no refugees whatsoever meet the provision’s criteria for treatment. The statutory provision intended to allow specially authorised practices to treat mentally ill refugees has failed and urgently requires revision.
- Funding the employment of language mediators: The reports also clearly indicated that one of the biggest hurdles to psychotherapy for mentally ill refugees is the lack of funding for language mediation. The treatment of refugees whose illnesses are in some cases acute must not be permitted to fail due to physicians and psychotherapists being unable to understand their patients. If ill refugees are to be treated, the employment of language mediators equipped with specialised cultural knowledge about the refugees’ countries of origin must be financed.
- Transfer of refugees to the regular health care system virtually impossible: The process of referring mentally ill refugees into the regular psychotherapeutic care system is severely hampered. Ambiguities about who is responsible for bearing costs, an excessively bureaucratic application process with long waiting periods, and a lack of funding for interpreter expenses have made it nearly impossible to provide psychotherapeutic care to refugees.
- Intercultural psychotherapy training required: The round-table experts agreed that equipping practitioners with socio-cultural knowledge is a key prerequisite for treating people from other cultures. Professional development training in intercultural psychotherapy and in working with interpreters is therefore essential
- Everyone with an illness has a right to medical assistance: At the end of the meeting, BPtK President Dr Dietrich Munz stated: “Both publicly and in our discussions with policymakers, we must continue to call for the appropriate treatment of mentally ill refugees. To date, serious deficiencies have existed that violate the ethical standards of psychotherapists and physicians.” Dr Ulrich Clever, the human rights commissioner of the German Medical Association added: “Everyone with an illness has a right to psychotherapeutic or medical assistance – regardless of his or her origin. Human rights don’t only apply to holders of a German passport.”
Mental health care for refugees and asylum seekers in Germany
What mental health facilities are currently available to refugees coming into Germany?
During the first 15 months of their stay, refugees receive benefits under the Asylum Seekers Benefits Act, which provides for medical and psychotherapeutic treatment only in cases of acute suffering, as well as acute and/or life-threatening illnesses. Mental disorders are only treated in exceptional cases, and only following a rarely successful application process. The extent to which a case of post-traumatic stress disorder (PTSD) is treated lies at the discretion of the authorities, who frequently reject applications for the psychotherapeutic treatment of refugees.
Following this 15-month period, most refugees are covered by Germany’s statutory health insurance scheme, which in principle includes psychotherapeutic treatment; however, the number of psychotherapeutic treatment spaces is strictly limited for all those covered by statutory health insurance in Germany: the average waiting period for an initial consultation with a psychotherapist is three months.
Another good source of psychotherapeutic care is a psycho-social centre for refugees and victims of torture, but they also have long waiting lists for consultations and treatment. In consequence, health care facilities are not sufficient to deal with the mental health of refugees coming into the country.
What further action needs to be taken to ensure that the mental health of refugees is cared for properly addressed?
The Federal Chamber of Psychotherapists (BPtK) is calling for mental disorders to be recognised as acute illnesses that require treatment. Furthermore, interpreters need to be paid to assist in providing psychotherapeutic care to refugees. It is generally impossible to provide psychotherapeutic care to refugees without the assistance of interpreters.
It should not be permissible to deport refugees who are suffering from Posttraumatic stress disorder (PTSD). Sending these people back to the place where they suffered their traumatic experiences is extremely stressful psychologically, and particularly perilous. In February 2016, the so-called Asylum Package II was passed by Germany’s two federal houses of parliament. As a result, post-traumatic stress disorders in particular are no longer among the “acute illnesses” that prevent deportation. It is said that mental disorders are “difficult to diagnose and verify”. Yet, for these illnesses there exists scientific, consensus-based and thoroughly verifiable diagnostic criteria. The BPtK calls for serious, life-threatening mental disorders to be handled as illnesses that fundamentally preclude the possibility of deportation.
BPtK-Guide for refugees parents : How can I help my child
Many refugee children have experienced in their homeland war and violence. The Federal Chamber of Psychotherapists (BPtK) has published a guide for refugee parents. The guide should help parents to understand their children better. The guide is available in English and Arabic, Farsi and Kurmanchi.
Download (english Version): A Guide for Refugee Parents
Download (arabic Version): "تنزيل الكتيب الاستشاري باللغة العربية للأمهات والآباء من النازحين "كيف يمكنني مساعدة طفلي المصاب بصدمة؟
Download (Farsi Version): دانلود: توصیە و راهنمایی برای والدین پناهجو
Download (Kurmanchi Version): Rêbera ji bo dê û bavên penaberan
- Approximately 82 million inhabitants, which corresponds to a population density of 230 persons per square kilometer
- Expenditure on health 2008: EUR 263.2 billion (10.5% of the gross domestic product)
- The costs caused directly by mental and behavioral disorders amounted to EUR 28.7 billion (19.9 % caused by depression)
Psychotherapy in the health care system
- Psychotherapeutic healthcare is financed for about 90 percent of the population by the statutory social insurance systems, covering the full range of inpatient care (hospitals, clinics), semi-inpatient care (day centers) and outpatient care (surgeries, hospital outpatient units). Everyone not covered by the statutory social insurance may opt for private health insurance.
- Psychotherapy is defined as a form of treatment for mental and behavioral disorders classified by the International Classification of Diseases.
- For outpatients, only behavioral therapy and psychodynamic psychotherapy are covered by the statutory social insurance system. For inpatients there are no restrictions on different psychotherapeutic approaches. Psychotherapists also adopt the other two approaches that are approved for training as a Psychotherapist: person-centered therapy and family therapy.
- Outpatient psychotherapy: patients have free access to psychotherapy. Indications are adjustment-, affective-, anxiety- , compulsive-, conversion-, dissociative-, eating-, sexual-, sleep-, somatoform-, personality- and psychotic disorders as well as behavioral and emotional disorders in children. Psychotherapy may also be indicated with somatic diseases, if psychological factors are pathogenetic or impair health. Patients can choose their therapist from a list of licensed psychotherapists. Limitations are set by approved session quotas for a specific approach (behavioral therapy: up to 80 individual sessions; psychodynamic therapy: up to 300 individual sessions). Group therapy sessions are also financed but only rarely offered in outpatient psychotherapeutic care.
- Psychotherapy is paid for after approval by the insurance company’s medical service.
- The “Guidelines for Psychotherapy” ensure that all patients will be cared for in a qualified and adequate way.
- Inpatient care for persons with mental disorder is offered by psychiatric and psychosomatic hospitals and rehabilitation centers. There are no restrictions regarding the use of different psychotherapeutic approaches in clinics. The average duration of treatment is 3 weeks in psychiatric and 6 weeks in psychosomatic hospitals.
- The profession 'Psychotherapist' is regulated by law. Qualification includes a minimum of 3 (full time) or 5 (part time) years of postgraduate training in an approved psychotherapeutic approach.
- Only psychologists and medical doctors can be trained in psychotherapy with adults. Child and youth psychotherapy may also be conducted by academic social workers and educationalists trained by the same postgraduate procedure as psychologists. Psychotherapists are graduates trained in an acknowledged psychotherapeutic approach (psychodynamic psychotherapy, behavioral therapy, person-centered therapy or family therapy) In 2009, over 28.000 psychological psychotherapists and 5.500 child and adolescent psychotherapists were working in Germany. Additionally, about 5.000 medical doctors were working in the field of psychotherapy during over 50% of their working time.
Psychotherapy for Depression
- The German "Nationale Versorgungsleitlinie Unipolare Depression" is an evidence- and consensus-based clinical practice guideline for patients with unipolar depression. In cases of moderate depression, either psychotherapy or pharmacotherapy are equally recommended; in cases of severe depression a combination of both is recommended.
Desirable Changes to Health Policy
- The density of psychotherapeutic care differs widely across Germany due to limitations on licensed Psychotherapists. As a consequence, in urban areas up to nine times more psychotherapists are licensed per 100.000 Inhabitants than in rural areas although there is no general difference in the mental health status of the population. A reform of the regulation system should lead to quotas based on morbidity instead of urbanity.
- In Germany, every psychological psychotherapist and child and youth psychotherapist is a compulsory member of a Psychotherapists’ Chamber. The supervision of occupational standards is among the principal responsibilities of the Psychotherapists’ Chambers. Therefore, the chambers, which are all members of the BPtK, work as public corporations. The BPtK, which represents some 34.500 psychotherapists in Germany, is thus the only professional organization to represent all psychological psychotherapists and child and youth psychotherapists at a national level.
Prof. Dr. Rainer Richter, Psychological Psychotherapist, Federal Chamber of Psychotherapists (Germany)
The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".
You can download the paper here.
The BPtK recently did an investigation on waiting times for outpatient psychotherapeutic care in Germany. It points out considerable waiting time and undersupplying in psychotherapeutic care. The average waiting time for an initial interview with a psychotherapist is three months and until the start of treatment usually close to another three months go by. Only 50% of the patients enter therapy.
BPtK Study (summary): Waiting Times for outpatient Psychotherapeutic Services [PDF]
BPtK Info Graphics: Waiting Times in Germany [JPEG]