Prof. Dr. Christine Knaevelsrud Freie Universität Berlin

1. Mental healthcarefortraumatizedrefugees in Germany –prevalence, symptoms und treatmentapproaches Prof. Dr. Christine Knaevelsrud Freie Universität Berlin UEMS, 15.10.2015

2. ApplicationsforAsylumfrom 2011-2015 Quelle: Bundesamt für Migration und Flüchtlinge

3. Decisions (august 2015) Quelle: Bundesamt für Migration und Flüchtlinge

4. AsylumSeekersBenefitsAct Basic benefits for food, housing, heating, clothing, hygiene, durable consumer goods Money to cover daily personal needs Benefits when being acutely ill/in pain, during pregnancy/birth Other benefits under specific circumstances depend on individual cases After 15 month immediate health care access but no cover of interpreter costs

5. Bozorgmehr & Razum, 2015

6. Psychologicalconsequences of traumaticevents

7. Typologie oftrauma (Maercker, 2009)

8. Prevalence of PTSD • General population • Men: 2% current; 4% lifetime • Women: 5% current; 10% lifetime • (Kessler et al., 2005 - National Comorbidity Survey -Replication) • Veteran populations • US/Vietnam: 9% current; 19% lifetime (Dohrenwend, 2006) • US/Gulf War: 3-16% (Sutker et al., 1993; Wolfe et al., 1999) • US/Iraq & Afghanistan: 12-13% (Hoge et al., 2004)

9. Prevalence of PTSD in refugees and asylum seekers

10. PTSD DEPRESSION TRAUMA SOMATOFORM DISORDER ALCOHOL/ SUBSTANCE ABUSE

11. Migration und Postmigration Act of migrationvoluntarily involuntarily Postmigration stressorsPredictors for development of psychological disorders

12. Migration and Postmigration 1st Phase Repression discrimination Sexual violence War Anxiety Isolation 2nd Phase Flight Traumatic Experiences prison life-threat 3rd Phase Exile Seekingasylum Unemployment New culture PTSD 4th Phase Forcedreturn Deportation High risk retraumatization    (Keilson 1979; Van Willigen, Hondius & Van der Ploeg 1995)

13. Postmigration stressors (3rd phase) • Iraqiasylumseekers in theNetherlands: (Laban et al., 2005) • Asylum procedure • No work permission • Work below level • Loneliness/missing family • Loss of cultural roots • Socioeconimic living conditions • Language problems • Uncertainty about future • Riskfactorsfor • Depression • PTSD

14. Daily stressorsand socialconditions Exposureto war-relatedviolence flight Mental health

15. Treatment approaches Psychotherapy German Guidelines for treatment of PTSD S3-Leitlinien (Flatten et al., 2011) Trauma-focused psychotherapy should be made available for all patients Treatment Significant reduction of PTSD symptoms, depression and anxiety (Lambert & Alhassoon, 2015; McFarlane & Kaplan, 2012; Slobodin & de Jong, 2014 ) Insufficient empirical basis for effective treatment approaches Few treatment approach for multiple traumatized patients

16. TRAUMA Months 6 <Months 12 Day 1 Month 1 PSYCHOSOCIAL SUPPORT (food, housing, visa, asylumprocess, language, work) Clinical Diagnosis PTSD (yes/no) Trauma-focusedpsychotherapy

17. Psychotherapyrecommendation traumafocusedapproach+ multimodal approach (integration+ legal issues+medicalsupport)

18. Symptom-relatedproblemswhenexploringpsychopathology • i.e. : • mistrust, isolation tendency • Inherent difficulty of communicability of traumatic events • Feelings of shame and guilt • Avoidance of talking about the traumatic event due to fear of loosing control • Association of the formal assessment/exploration with past interrogation /torture experiences • Dissociation-based amnestic difficulties & limit capacity for affects • Difficulty to concentrate • (Knaevelsrud et al., 2012)

19. Cultur-specificapects in thetherapeuticsetting • i.e.: • Different definition of self in collective and individualistic cultures • Mode of communication (nonverbal/ verbal) • Code of conduct to unfamiliar persons/authorities • Social consequences for victims of (sexual) violence due to existing taboos • Concepts of help and support/definition of thetherapist‘srole • Meaning of symbols/dreams • Meaning of disorder/illness

20. Psychoeducation Cultural context influences development of disorder, interpretation of disorder and concepts of coping with the disorder Specifically developed for refugees, victims of war and torture 10 modules Assessment, understanding, competence learning information- und training sheets group therapy or conventional dyadic setting

21. Narrative ExposureTherapy

22. short-term • culturallyuniversal intervention • Low incomesettings (e.g. refugeesettlements in Uganda) • Multiple traumas • toconstruct a chronological • narrative of his/her wholefocusing on traumaticexperiences life

23. Trauma Paintherapy Dysfunctional Cognitions intrusionen PTBS - Kreislauf Avoidance Hyperarousal Schmerz-Kreislauf Fear-Avoidance Beliefs Pain Perpetual Avoidance Model (Liedl et al.. 2008)

25. Pharmacological treatment • Exclusively pharmacological treatment is insufficient (Flatten et al., 2011) • Education • Clarification of current pharmacological medication consumption • Explanation of dosage and intake rules • Explanation of assumed mechanisms of change

26. Conclusion • Multimodal therapy approaches • Psychotherapeutic treatment • Medical support • Legal support • Psychosocial integration • Qualified assessment • Prompt decision on the asylum process • Treatment of refugees in regular mental health care settings not just specialized treatment centers • Covering cost for interpreter