According to estimates by the United Nations High Commissioner for Refugees (UNHCR), more than 3 million people have already fled from Ukraine. As of March 18, around 200,000 of these refugees had fled to Germany, according to information from that country’s police force.
They are escaping from bombs, tanks, and the destroyed infrastructure of their home country. The refugees need not only housing, but also medical care, psychosocial support, and in some cases, psychotherapeutic treatment.
In the German Association of Psychosocial Centers for Refugees and Victims of Torture (BAfF), 47 psychosocial centers have been organized that are specialized in the care of refugees with posttraumatic disorders. In 2019, around 25,000 clients were treated across 42 psychosocial centers. The BAfF practice guidelines “Trauma-Sensitive and Empowering Interaction with Refugees” summarize the most important expertise.
How widespread are posttraumatic disorders among refugees? What does trauma-sensitive interaction with refugees look like? Is Germany sufficiently prepared to provide psychosocial care to the war refugees? Medscape spoke about these and other topics with Lisa vom Felde, advisor for special protection needs and psychosocial care at the BAfF.
Medscape: How can mental support be provided to the newly arriving refugees?
vom Felde: It is important to know that many serious mental breakdowns can be prevented. Research on this shows that when refugees are no longer in the acutely threatening situation, but rather in objective safety, ie, here in Germany for example, they develop a feeling of control if support is given in this phase.
This includes being able to map out their lives themselves, sending children to school, or for adults, having the opportunity to work a meaningful job. All these support structures can dramatically reduce the risk of developing posttraumatic stress disorder (PTSD) or another posttraumatic disorder.
Medscape: Not every refugee is traumatized or suffering from a posttraumatic disorder. How widespread are posttraumatic disorders among refugees?
vom Felde: There are international studies that show that approximately 30% of refugees suffer from PTSD and 30% develop a depressive condition, and these can of course occur simultaneously. These are international figures. In Germany it may be similar, but the figures are not representative for Germany.
Medscape: Around 12,000 to 15,000 more refugees are arriving from Ukraine every day. Is Germany prepared for the psychosocial care of these people?
vom Felde: Germany is not sufficiently prepared for the flow of refugees from the war in Ukraine.
The problem is that for a variety of reasons — including due to the legal conditions — the people arriving here cannot easily access the regulatory system. This also applies for people from Ukraine. They do get a Permit of Residence for Temporary Protection pursuant to §24 of the Residence Act. But this also includes the receipt of benefits via the Asylum Seekers Act.
The result is that the psychosocial centers are commonly the only point of contact. Annually, 25,000 people are treated there. Even so, the capacity of the psychosocial centers only covers a small part of the actual need right now.
In addition to this, the government only provides approximately 9% of the financing for the psychosocial centers at present. The rest is financed by other means — commonly European funds — or other project funds. Germany is not meeting the requirements that exist due to international obligations about which I spoke earlier.
Medscape: Are there enough Ukrainian-speaking therapists for the support?
vom Felde: There are not enough Ukrainian- and Russian-speaking therapists or social workers to cover the care. But this also applies for all other language groups.
The PSZ [Psychosocial Center] employees therefore usually work with interpreters. They have decades of very good experience in this. Interpreters do not just provide support in terms of language, they are also cultural mediators, and this gives some refugees a feeling of security that there is a third, supportive person in the room with whom they can communicate directly.
The problem here, too, is that there is no financing, and these are not fixed in the Social Security Statute Book, for example. Therefore, the majority is financed via project funds or donations. In some federal states, there are pools of interpreters that are financed through state resources.
We need a legal right to language mediation so that people who do not speak German can be cared for appropriately. Many people need someone to translate for them — including for medical appointments.
Most of our member centers are now working on developing capacities for Ukrainian language mediation. In some psychosocial centers, there are interpreters who speak Ukrainian or Russian. But then again, undergoing therapy in Russian is not possible for everyone. Some will also say, “I do not want to speak the language of the aggressor in therapy, even if I am proficient.”
Medscape: In many cases, refugees’ posttraumatic disorders only come to the surface long after the traumatic event, since other demands, such as physical disease, need for security, etc take priority. What does this mean for psychosocial care?
vom Felde: Posttraumatic disorders can develop very early on. PTSD, for example, can occur just a few weeks after the trauma. However, people arriving here are mostly occupied with other things. First priorities are: where am I living, how will my residency proceed, can I even stay in Germany or will I be deported, can my child go to school, and so on. People also often remain in stress mode for a long time due to their precarious accommodation situation and insecure residency status.
In terms of psychosocial care, this means people seldom require therapy straight away. Instead, hence the psychosocial approach, they first need to meet a whole host of other important needs.
For some, a posttraumatic disorder only comes to the surface when they are finally relaxed. And there are people who have been living here for years and eventually suffer a breakdown. The trigger is never easy to identify. Maybe because they can no longer bear to go on living for years in uncertainty. Or they miss their family and are worried because they are still living in their home country.
Medscape: Who is entitled to trauma treatment?
vom Felde: If you are referring to psychotherapy, you need to know that someone applying for asylum in Germany has no health insurance for the first 18 months of their stay. Instead of this, they have limited healthcare provision, which is stipulated in the Asylum Seekers Act. In some federal states, asylum seekers still receive an electronic health card; in other federal states they always need to apply for a health insurance certificate with the social welfare office. In this period, only acute illnesses and pains can be treated, and how this is interpreted is always slightly dependent on the responsible official.
Medscape: Let’s suppose that a refugee suffers from panic attacks. Will this person receive any treatment?
vom Felde: Unfortunately, that is not always the case. It often depends on whom the person turns to. The first points of contact are usually offers of medical care at the accommodation. How the physicians handle such requests can vary.
Another decisive factor is whether the affected person has access to an advice center that maybe offers them support in requesting therapy, or whether the person is in contact with a psychosocial center. The psychosocial centers do not invoice most treatments with the health insurance funds. Treatment in the psychosocial centers is free of charge and financed through other means. Anyone can go there — regardless of residence document — and also in their first 18 months.
Medscape: How is the need for psychosocial treatment determined?
vom Felde: Psychosocial care is based on the client’s needs and is incorporated into a holistic approach that comprises social work and educational offers, counseling, psychological and psychotherapeutic offers and, if necessary, medical aid.
In accordance with European legislation, asylum seekers with particular needs — which includes asylum seekers with mental conditions or survivors of serious violence — have the right to receive necessary medical and psychotherapeutic support. They are entitled to identify their specific needs and to have the implications of these needs be addressed.
There would be the opportunity, for example, to set up special consultations for this, to provide open offers with a permanent contact person who will identify a need and then initiate the corresponding implications. It is not always about therapy. Sometimes the specific need can also mean that the person affected needs a particular kind of accommodation. Or a special consultation regarding the asylum procedure because they are worried about their residence document. If they understand their legal situation better in the course of a consultation, this can calm them, and the affected person can sleep better again.
The needs can be quite diverse. Not everyone needs therapy; therefore, we also refer to a psychosocial approach to treatment.
Medscape: In your practice guidelines “Trauma-Sensitive and Empowering Interaction with Refugees,” which are currently out of print but available online, the BAfF provides information about trauma and escape, structural conditions for psychotherapy with refugees, handling symptoms of trauma and finding stability in stressful situations. In it, a closet is chosen as a metaphor for traumatic situations and the processing of these situations. Could you explain this image to me a little?
vom Felde: The metaphor of a disorganized closet symbolizes the memories retained during PTSD and how therapy could help. It is important to note that not every person who has experienced trauma goes on to develop PTSD. This is just one of many possible conditions, and some other people never even develop a mental illness.
Memory disorders can be a result of traumatic situations. Certain memories may then be stored with a structure different to the memories of nontraumatic situations.
The memories stored in an unstructured manner are then symbolized by the disorganized closet. Its door does not close properly anymore. It springs open at the slightest of touches, and the clothes all fall out. This describes a possible symptom of PTSD: certain stimuli that are not threatening for other people remind the affected person of their traumatic situation, which therefore leads to this person being triggered.
For example, it is often described that for some people who were persecuted by governmental institutions in their homeland, the sight of a police officer or someone else in uniform triggers flashbacks in them. The affected people then experience their earlier emotional state again and are inundated with their traumatic memories. This corresponds to the image of the clothes randomly falling out of the opened closet door.
These flashbacks are very stressful, especially when they occur in everyday life. For the affected person, a flashback feels just as if they were back in that situation with all of the associated emotions — panic, excessive stress, doubt, helplessness.
In trauma therapy, after a phase of stabilization, the idea is to carefully deal with these traumatic memories. There are various potential methods to do this. The aim of the therapy is to arrange the traumatic memories. Just like in an organized and tidy closet these memories are still there, but you have control over them. You know where these memories are and can also access them, but you can also prevent having flashbacks when doing so.
Medscape: Do children and adults react differently to war, violence, and destruction?
vom Felde: To begin with, in principle, everyone reacts differently to traumatic situations. It depends on the individual coping methods that every person has, but also predominantly on their social surroundings, ie, what opportunities for support there are.
Of course, there is a difference between children and adults based on children’s specific developmental phases. If situations hold sway during critical developmental phases in which the appropriate conditions for healthy development simply do not exist, this can have long-term implications.
It is particularly important with children to make sure that extremely stressful situations are kept as short as possible, that parents are encouraged to support their children and that a child-friendly environment is created. On the other hand, children are extremely resilient and can somehow manage through the most difficult situations if they at least have support from their most important caregivers and if the stressful situation is not a long-term situation.
Medscape: Do men and women differ in their reactions?
vom Felde: Just like with many mental conditions, there are clear differences. These are dependent on how people — depending on their socialization — can or may express stress and have a feeling about it.
For example, due to their socialization, it can be more difficult for men to express sadness and show presumed weakness. Men in families also more often think that they must be strong and hold the family together. This can lead to stresses being expressed in other ways, and those stresses may not be communicated so openly.
Medscape: Thank you very much for the discussion.