Transcript Dr Knaevelsrud – Care of Refugees in Germany

Mental health care for traumatized refugees in Germany –
prevalence, symptoms und treatment approaches
Prof. Dr. Christine Knaevelsrud
Freie Universität Berlin
UEMS, 15.10.2015
Applications for Asylum from 2011-2015
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Quelle: Bundesamt für Migration und Flüchtlinge
Decisions (august 2015)
Quelle: Bundesamt für Migration und Flüchtlinge
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Asylum Seekers Benefits Act
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
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Bozorgmehr & Razum, 2015
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Psychological consequences of
traumatic events
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Typologie of trauma
Accidental trauma
man-made trauma
Singular Trauma
car accident
robbery, rape
Long-term trauma
flooding, earth-quake war crime, toture,
sexual abuse
(Maercker, 2009)
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Prevalence of PTSD
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General population
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Men: 2% current; 4% lifetime
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Women: 5% current; 10% lifetime
(Kessler et al., 2005 - National Comorbidity Survey -Replication)
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Veteran populations
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US/Vietnam: 9% current; 19% lifetime
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US/Gulf War: 3-16%
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US/Iraq & Afghanistan: 12-13%
(Dohrenwend, 2006)
(Sutker et al., 1993; Wolfe et al., 1999)
(Hoge et al., 2004)
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Prevalence of PTSD in refugees and asylum
seekers
Asylum seekers in Germany
40% PTSD
(Gäbel et al., 2006)
Victims of torture, war and
displacement (Steel et al., 2009)
(Olsen et al., 2007)
31% PTSD
31% Depression
76% chronic pain
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PTSD
DEPRESSION
TRAUMA
ALCOHOL/
SUBSTANCE
ABUSE
SOMATOFORM
DISORDER
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Migration und Postmigration
Act of migration
voluntarily
involuntarily
Postmigration stressors
Predictors for development of psychological disorders
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Migration and Postmigration
1st Phase
2nd Phase
Repression
Flight
discrimination
Traumatic
Sexual violence
Experiences
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War
prison
Anxiety
life-threat
Isolation
3rd Phase
4th Phase
Exile
Forced return
Seeking asylum
Deportation
Unemployment
High risk
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New culture
retraumatization
PTSD
(Keilson 1979; Van Willigen, Hondius & Van der Ploeg 1995)
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Postmigration stressors (3rd phase)
Iraqi asylum seekers in the Netherlands: (Laban et al., 2005)
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Asylum procedure
No work permission
Work below level
Loneliness/missing family
Loss of cultural roots
Socioeconimic living conditions
Language problems
Uncertainty about future
Risk factors for
• Depression
• PTSD
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Daily stressors and
social conditions
Exposure to
war-related violence
flight
Mental health
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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
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TRAUMA
Day 1
Month 1
Months 6
<Months 12
PSYCHOSOCIAL SUPPORT
(food, housing, visa, asylum process, language, work)
Clinical Diagnosis PTSD (yes/no)
Trauma-focused psychotherapy
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Psychotherapy recommendation
traumafocused approach + multimodal approach
(integration + legal issues + medical support)
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Symptom-related problems when exploring
psychopathology
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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)
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Cultur-specific apects in the therapeutic setting
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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 the therapist‘s role
Meaning of symbols/dreams
Meaning of disorder/illness
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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
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Narrative Exposure
Therapy
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short-term
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culturally universal intervention
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Low income settings (e.g. refugee settlements in
Uganda)
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Multiple traumas
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to construct a chronological
narrative of his/her whole focusing on traumatic
experiences life
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Trauma
Pain therapy
Dysfunctional
Cognitions
intrusionen
PTBS - Kreislauf
Avoidance
Hyperarousal
Schmerz-Kreislauf
Fear-Avoidance
Beliefs
Pain
Perpetual Avoidance Model (Liedl et al.. 2008)
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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
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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
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