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Inside the Psychological Care for Refugees in Germany

Interview with the therapists

In 2015, close to 1 million refugees arrived in Germany. What felt like overnight, the global headlines spilled from the screens onto the European streets. Amidst ensuing legislations and public sentiments, the newcomers faced the task of dealing with the aftermath of their traumatic journeys and adjusting to a new, foreign life. In various centers across Germany, mental health professionals have been working in tandem with social workers, medical doctors, language teachers and specially trained interpreters to provide comprehensive, multifaceted care for the refugees. According to Dr. Nadine Stammel who leads the research department of the Berlin Center Of Torture Victims (BZFO), this multi-modal approach has had positive outcomes, with preliminary findings showing a decrease in trauma-related disorders and an increase in quality of life.

A series of interviews with therapists working with refugees in Germany indicates that the scenario is complicated for everyone involved. The centers focus on refugees who suffer from trauma-reactive disorders. Most of them experience post-traumatic stress disorder (PTSD) symptoms. They also suffer from depression, chronic pain, anxiety. They don't share a common language with the therapists; nor cultural values on what it means to seek psychological counseling. For some, the extent of their traumas is unthinkable, even for the seasoned eyes and ears of mental health professionals. “I have been working with torture and trauma victims for many years,” says Gisela Scheef-Maier, a psychotherapist from BZFO, “but their stories still shock and overwhelm me.” Some try coping by suppressing their memories. Others fall into avoidance patterns, only to add more layers to the scope of their conditions. Some think that their nightmares are caused by bewitchment. Most deal with the discrepancy of their expectations towards the host country not matching their new realities. Then there is the lacking trust: towards the foreign therapists, or the native interpreters. Yet, they work together side by side, day after day, to overcome these barriers – cultural, linguistic, and psychological – for the common goal of rebuilding hope. “We do our job because we have faith that it works,” says psychotherapist Katrin Kammerlander from REFUGIO in Munich, “otherwise we wouldn't be able to do it.”

What kinds of therapies do you use with your refugee clients?

Gisela Scheef-Maier: Our clients have very complex histories of traumatic experiences with many overlapping problems, which makes the use of standardized treatment programs not so helpful. Besides posttraumatic symptoms, separation or loss of family members combined with feelings of guilt, worry and grief play an important role. Their trauma is a result of not only the experiences at home, but also of what they went through during their flight. We assess each client during an extended diagnostic phase at the beginning of their treatment, then decide on the best approach for them. We take elements from different therapy methods such as cognitive behavioral therapy, narrative exposure therapy, testimony therapy and create a personalized treatment plan that we think will benefit the client best.

Katrin Kammerlander: Our clients come with various issues concerning not only their past traumas, but also their everyday life. A lot of times, they are faced with overcrowded shelters, lack of German courses, and little access to the general healthcare system. For all these kinds of problems, we have social workers to assist them. That makes it easier for the therapists to work on the psychological problems. Of course, the uncertainty about their future makes the stabilizing more difficult. If the clients are experiencing dissociations, intrusions and flashbacks, we often teach them skills from dialectical behavioral therapy. Once there is an improvement, we go into their trauma, step-by-step. When clients don't want to tell me everything, I tell them it’s OK. They decide the pace, and they decide what to share. Having control over the situation is very important for them. At the same time, I also push them a little, because confrontation with the trauma in a therapeutic setting will help to reduce the symptoms. And it is an important step to integrate the traumatic experiences into their life stories.

What are some of the biggest challenges of the therapy?

Katrin Kammerlander: It makes a huge difference in their healing process if they know that they get to stay in Germany. If they are certain of the possibility of a good future, where they can feel safe and integrated into the new society, then they can concentrate on their psychological problems. For those clients who are always afraid because they don’t know if they are going to be sent back, and who don't know if it is even worth integrating, it’s a lot more difficult to face their problems. Then there are those who left family members behind, or those who lost someone during their flight and they don't know what happened to them. They struggle with constant feelings of It was my fault or Where is my child? If you are grieving, at one point you can begin to look forward. But they can’t go through the normal grieving process, because they don't know whether their family members are alive or not. This is one of my biggest challenges, because there is so little I can do. In those cases, we try to find support from people of similar cultural backgrounds who have been through similar experiences. We try to take away the guilt as much as possible, and to show them that they are not alone.

What is it like to work with interpreters during your therapy sessions?

Nadine Stammel: We have a pool of trained interpreters who help us during our therapy sessions. After each session, there is an exchange between the interpreter and the therapist to discuss the cultural nuances. The interpreters are trained to translate in first person, word-for-word, and because of this, they can sometimes feel the strain of the traumatized stories that they are translating.

Katrin Kammerlander: The interpreters are very helpful because they not only translate, but also become our cultural bridges. They help the therapists understand whether what we are saying is culturally appropriate or not. Interpreters can also help to explain the reactions of the clients.

What advice do you give your clients in helping them to integrate?

Katrin Kammerlander: We tell them to learn the language. Then to go out there and practice the language with the locals. Sometimes, I give them homework to talk to five different people before our next session – even if it’s just saying “hello.”

Gisela Scheef-Maier: My advice is don't withdraw. Start to do something. Avoid avoidance behavior.

What have you learned from your experiences as a therapist for the refugees?

Katrin Kammerlander: The stories that I hear make me think that there is nothing a human won’t do to another human. On the other hand, I feel that people who have gone through horrible experiences can get better if they find another human. You need humans for both – for hurting and for healing. Of course the therapy helps, but to have a place where they can feel safe, and where they can start to learn to trust again is the biggest gift I can give them. To hear their stories and to see that they trust me, to realize that not all humanity is evil - that’s my biggest contribution. I offer myself as a therapist with my techniques, but most importantly, I offer myself as a human being. My favorite part of the job is when my clients tell me that on some nights, they no longer have nightmares. And when they tell me that even though they would like to keep coming to see me because they like it here, they don't need me anymore.

Many thanks to Katrin Kammerlander (REFUGIO München), Gisela Scheef-Maier (BZFO), Dr. Nadine Stammel (BZFO), and Dr. Tanja Waiblinger (BZFO) for their generous time and insights.