Rising numbers of refugees mean that in the course of their daily professional lives, doctors and psychotherapists increasingly come into contact with patients who suffer from the psychological and physical consequences of war, persecution and displacement. Addressing trauma-related mental illness and psychosocial problems among migrants from crisis areas can place high demands on doctors and psychotherapists in terms of culture- and migration-sensitive communication skills as well as knowledge of current and historical social contexts.

For example, an assessment or treatment situation might call for knowledge of other countries in terms of the specific characteristics of communication, taboos and gender roles, and behaviour when dealing with authority and rules. Diversity competence, moreover, is also required; this must be understood as an extension of the usual social and cross-cultural communicative medical/therapeutic expertise. Such competence allows the practitioner to understand the effects of so-called ‘diversity dimensions’ such as age, gender, sexual orientation, disability, religion, sociocultural background and skin colour on the illness, in both the society of origin and in the host society (Joksimovic 2010).

When dealing with diversity dimensions, it is important that they do not describe character traits, but rather the categories by which people experience exclusion or discrimination regardless of individual skills. Diversity competence explicitly includes the willingness to self-reflect on ones own cultural embeddedness, prejudice-conscious communication, perception of power asymmetries and discriminatory structures in the host society. The knowledge required for such competence, including active skills and specific attitudes in dealing with people from crisis zones with psychological and psychosomatic problems, is barely touched upon within medicine and psychology degrees nor through further training. Unfortunately, the few existing training opportunities are utilised only insufficiently as yet.

This leads many doctors to assume that their medical intervention and the medical profession are neutral (Beagan and Kumas-Tan 2009; Berger 2008). In so doing, they overlook the fact that Western medicine has its own culture, in that it contains values, beliefs, norms and language that directly influence their medical practice (in terms of preventive, diagnostic and therapeutic treatment as well as the formulation of reports, certificates, attestations, etc.) (Smedley et al. 2009). In the health system, awareness for this is only occasionally available so far. As such, the medical and psychotherapeutic care of mentally ill immigrants from crisis areas remains a particular challenge for health services.

General practitioners play a key role in the initial stages of detecting indication of mental illness in patients who have had to flee their home countries. They are often the first point of contact for refugees entering the health system of the host country. Many GPs feel insufficiently educated and trained regarding this task. A study conducted in Switzerland, for example, found that torture and its consequences were not mentioned explicitly as a problem by patients, nor named as such by the doctors, in any of the consultations examined, despite the fact that 110 of 1,477 diagnoses among refugees in primary care consultations were clearly associated with maltreatment (Junghanss 1998). There is an especially great risk of traumatic experiences being overlooked as a potential cause of physical complaints for which there is no adequate organic explanation.

Scientific studies seem to indicate an increased risk for mental and physical disorders in refugee populations (Fazel et al. 2005; Johnson and Thompson 2008; Kruse et al. 2009; Laban et al. 2005). This risk is increased in comparison with both the native population (Sundquist 1993a, b) and so-called ‘voluntary’ migrants (Cervantes et al. 1989; Klimidis et al. 1994; Lin et al. 1985; Sundquist 1995). Above all, increased rates of post-traumatic stress disorder (PTSD), depression, pain and somatoform symptoms are found among refugee populations. A systematic review of 20 studies showed that a high rate of PTSD is approximately ten times more likely to be found among refugees than among an age-matched native population (Fazel et al. 2005). Chronic forms of PTSD are often reported. In a study by Marshall et al. (2005), for example, symptoms of PTSD were found in 63 % of refugees from Cambodia, 20 years after fleeing to the United States.

PTSD (ICD-10: F43.1) is the result either of a brief but highly stressful or disturbing event or of a longer-lasting period of such events, accompanied by feelings of fear and helplessness. According to the criteria of ICD-10, the symptoms can occur days or months after such an event, which is one that would be stressful for almost anyone. PTSD is characterised by the following symptoms: repetitive re-experiencing of the traumatic event through intrusive memories (flashbacks), dreams or nightmares; avoidance of activities and situations that might trigger memories of the trauma; and (in most cases) a state of autonomic hyperarousal, startle response (‘jumpiness’), impaired concentration and/or sleep disturbance. A feeling of emotional dullness or numbness also commonly occurs.

PTSD is associated with a high risk of co-morbidity, the most common co-morbid disorders being depression and substance abuse. Somatoform disorders are also often co-morbid with PTSD (van der Kolk et al. 1996). However, only a few studies have dealt with these co-morbidities among refugees (Cheung 1993; Hinton et al. 2008; Kruse et al. 2009), although it is known that somatoform disturbances among war veterans and refugees lead to an increased utilisation of health services (Engel et al. 2000).

The literature on mental disorders among refugees increasingly reports psychotic disorders. There is empirical evidence to suggest that cumulative traumatic events may actually be a causal factor for the later development of psychosis (Fisher et al. 2010; Larkin and Read 2008; Shevlin et al. 2008). The co-morbidity between PTSD and psychosis among traumatised refugees is now being studied in more detail (Gerritsen et al. 2006; Kroll et al. 2011; Schreiber 1995). But the way psychotic symptoms are perceived, expressed and healed are also often strongly linked to sociocultural traditions.

From our clinical practice, we observe that traumatised people from crisis areas often report altered experiences and perceptions that have strong similarities with psychotic disorders. The basic similarities between traumatic disorders and psychotic disorders lie in a distortion of perception and a (usually temporary) loss of reality – in the form of vivid intrusions in traumatic disorders and hallucinations in psychotic patients. Viewed superficially, the symptoms may seem identical (hearing voices, paranoid experiences, hallucinations); the aetiology and symptom development are however different.

Cultural differences and language problems can make it difficult to differentiate between the two, meaning that there is an increased danger of overlooking possible traumatic origins of such symptoms in refugees who have recently arrived and have an insufficient knowledge of the language of the host country. Misunderstandings are more likely when doctors and therapists are unaware of the difficulty described and lack the relevant experience and skills in this field. Usually, the symptoms are then treated exclusively through psychopharmacology. Since these substances have side effects and may adversely affect the long-term prognosis of PTSD, clinical differentiation and critical diagnosis are of urgent necessity.

Another consequence of war- and torture-related trauma is the profound personality changes which can be associated with the diagnosis of ‘enduring personality change after catastrophic experience’ (ICD-10: F62.0). Such changes may have been preceded by the clinical picture of PTSD. The former disorder is characterised by a hostile or distrustful attitude towards the world. In addition, social withdrawal and feelings of emptiness or of constantly being threatened are all part of the pattern of symptoms. Traumatised refugees and their relatives frequently perceive disturbing changes in character traits which are particularly important to them, such as their sense of responsibility towards their family. For example, a traumatised patient might observe an indifference towards his children and grandchildren but report that they had been particularly active and interested in the development of their children before the trauma and used to be perceived as such by others. Such changes may lead to serious internal destabilisation and insecurity, especially if these changes relate to characteristics that had been central to their identity. This can lead to conflicts in the refugee’s family environment (which is often stressful already) and can thus produce a severe psychological strain not only on the affected individual but also among relatives and for the next generation. In extreme cases, these changes can be experienced by the affected individual as a personal failure and thus as a victory of whoever caused them suffering. It is important to remember that the psychological and psychosomatic consequences of traumatic experiences are subject to broad individual differences and cannot always be clearly mapped with the current classification systems.

Factors that come into consideration as predictors of the above-mentioned trauma-related disorders include stress and traumatic experiences in the person’s country of origin, living conditions in the host country and personal resilience. Stress factors before migration include rape, being a prisoner of war, combat experiences in war, house searches, unlawful detention, physical and psychological abuse, living in hiding, witnessing injury or death of people one is close to and/or the loss of these people and being unexpectedly confronted with corpses and body parts. In 2012, people were abused and tortured in 112 countries across the world (Amnesty International 2013). Torture, thus, should not be seen as an exception among the refugee population (Eisenman et al. 2003; Holtan et al. 2002). Undoubtedly, such experiences increase the risk of mental disorders in refugees several times over (Mollica et al. 2001; Silove et al. 1997).

Another risk factor for the development of illness and/or the illness taking an unfavourable course can be the treatment of asylum seekers by the host society; this is often marked by exclusion. Many of the impairments to (mental) health become manifest only after a certain latency, in connection with the living conditions in the host country (Laban et al. 2004). Levels of psychological distress after migration therefore differ between comparable refugee populations, depending on conditions in the host country (Warfa et. al. 2012). Silove et al. (2007) give a detailed description of the role of post-migration risk factors in psychological problems among populations exposed to mass trauma and displacement.

Since the current diagnostic criteria do not adequately reflect the wide range of possible psychological and psychosomatic consequences of flight and migration, a so-called progressive diagnosis is preferable when working with patients from crisis areas who have such a history. Only through a detailed exploration of the course taken by the disorder is it possible to avoid an overhasty, incorrect ‘spot’ diagnosis upon which basis a potentially inappropriate treatment might otherwise be initiated.

In our work, an in-depth, psychodynamically oriented diagnosis (involving taking a disorder-specific biographical and social history as well as a culturally sensitive survey of psychopathological findings) has proven its worth. In so doing, especially in cases where the clinical picture is unclear, the aim is to gain an overview of the following aspects (Joksimovic 2009):

In our experience, refugees are rarely consulted sufficiently about their medical history and are prescribed medication even in the absence of improvement. In practice, this generally leads to an increased use of various substance groups among traumatised patients (SSRIs; tricyclic antidepressants, sleep-inducing antidepressants with a dual mode of action; neuroleptics and hypnotics) when the traumatic origin of the symptoms is not recognised (Joksimovic et al. 2013). The risk of this increases with the presence of linguistic and sociocultural barriers. Therefore, when disease-related problems of understanding occur because of linguistic difficulties, language and integration mediators must be used in the diagnostic procedure. In addition, in a cross-cultural treatment setting, the patient may interpret the context in a markedly different way from that of the practitioner.

This point can be clarified through the example of hallucinations: as an isolated symptom, especially in cross-cultural settings, hallucinations initially have very little meaning. They may occur in psychotic, depressive, traumatised and physically ill people but also in healthy individuals. Ivezic et al. (2000) found ‘psychotic’ symptoms such as auditory hallucinations in approximately one fifth of Croatian war veterans who were diagnosed with PTSD in psychiatric inpatient care. These hallucinations were described by the patients as being more intense than typical traumatic intrusions, but their content was still related to the trauma. ‘Hearing voices’ alone, then, should not limit the potential diagnosis too rashly (such as an immediate diagnosis of an illness from the schizophrenic group). For patients who come from a sociocultural milieu in which strong spiritual connections (such as to the ancestors) do not represent anything extraordinary, hearing the warning voice of the ancestors, for example, is not to be clinically regarded as auditory hallucination per se. Of course, this would be assessed differently if it occurred in combination with sleep disturbance and a sense of being driven to fulfil an order.

Making an overhasty diagnosis can be a way for practitioners to circumvent or resist the uncomfortable feelings associated with diagnostic uncertainty and engaging in patients’ horrific traumatic experiences. Regular supervision under the guidance of cross-culturally competent colleagues can be of great help and support in such cases.

In the treatment of mentally ill and traumatised refugees, the following problem areas in the cross-cultural context are often identified:

On top of this, specific problems (such as doctors’ and therapists’ lack of knowledge on refugees’ living conditions and the resulting health risks) exacerbate the problems above. Refugees’ living situation is of special complexity, particularly due to restrictive conditions as pertaining to residence and basic social security. Only a small proportion of all asylum applicants receive official recognition or subsidiary protection by the German Federal Office for Migration and Refugees (BAMF) and thus a residence permit, and often only after several years; only such a permit allows the attendance of an integration course, receipt of unemployment benefits, choice of which health insurer to register with and uptake of work or a training course, etc.

Without or prior to receiving such a permit, many refugees with an immigration status such as the ‘toleration’ status usually have to endure very poor living conditions, often over a number of years; this commonly includes living in extremely cramped accommodation as well as having no legal right to work, attend language or integration courses or receive normal social benefits (being subject to the separate Asylum Seekers Benefits Act). In terms of psychotherapeutic care, this means that the social welfare offices are the authority responsible for reviewing the necessity of health department services. All measures that go beyond the treatment of acute and painful conditions require prior approval by the social welfare authority (i.e. not health professionals); in practice, this represents a high bureaucratic hurdle that often triggers resignation on the part of those affected and incomprehension and anger on the part of professionals. In some cases, treatments which are strongly indicated are delayed or made completely impossible.

Another specific feature of working with people who come from conflict areas is working on the consequences of the overwhelming force of traumatic experiences; as a rule, such experiences can only be stored in human memory in fragments due to the impairment of regulatory subcortical and cortical exchange processes. Traumatic experiences are stored as discrete sense impressions and usually stay insulated from contexts of experience which would otherwise be potentially conducive to relativising and processing the traumatic experience (Brenneis 1998; Markowitsch 1998; van der Kolk et al. 1998; Wessa and Flor 2002). As such, stored traumatic material can be reactivated by relatively weak cues and is re-experienced in direct, film- and image-like form or through reactivated body memories or unregulated and endlessly repeating streams of thought (intrusions, flashbacks). The ease of triggering of traumatic material alongside the relatively undeveloped verbal memory traces represents a major obstacle to the subsequent processing of traumatic experiences (Kunzke and Güls 2003).

This type of re-experiencing, no matter what the traumatic background, has no healing or processing effect; from a neurobiological point of view, information above a certain emotional intensity – here mostly fear or anger – can no longer be used in a new way. In such cases, the cortical processing mechanisms are turned off, so to speak, and more ‘primitive’ subcortical processes step in and take over (Acheson et al. 2012; Yehuda 2002). This must be taken into account in considerations pertaining to intervention techniques in psychotherapy. If there is evidence to suggest past experiences of torture, it is also important to avoid treatments and postures (if medically justifiable) that trigger re-experiencing the trauma. Dental examinations of people who have suffered tooth torture, gynaecological and urological examinations in cases of sexual violence and ECG studies in people who have experienced torture by electric shock must all be performed with great sensitivity to the patient. This is only possible if a relationship of trust has been created between a doctor and a patient; otherwise, treatment intended to heal could lead to re-traumatisation or serious misunderstandings. Collaboration between a patient’s psychotherapist and their doctor could help in such cases.