On the basis of statutory provisions in the German Social Security Code (Book V, §118), the PIAs fulfil a specific mandate to provide care for those with a mental illness who, because of the nature, severity or duration of their illness, require treatment services which are close to those provided in hospitals. Such treatment is for patients who are not adequately catered for by any of the German ‘vertragsärztliche’ ambulatory medical care services (Koch-Stoecker 2011).

As part of the concept of intercultural openness at the PIA at Charité University Psychiatric Clinic at St. Hedwig Hospital, all the employees work with patients with a migration background as part of their role as reference therapist. Regular intervision, case discussions with other therapists, team meetings and supervision in individual cases all ensure that the therapeutic treatment is regularly reviewed, that problematic areas are named and shed light upon and that future courses of action are clarified. Such teamwork offers an opportunity for the discussion of social aspects and elements which are specific to certain cultures or to migration as a whole. Every patient, regardless of origin or nationality, is looked after by two members of the multi-professional team, one physician and at least one other health-care professional. This is in order to prevent discontinuity in the therapeutic relationship when one of them is absent due to annual leave or illness. Each patient therefore has two points of reference who regularly exchange information and impressions about the current situation and cooperate closely in crisis situations – an example of interprofessional teamwork (Schouler-Ocak 2000) in action!

When engaging in an intercultural treatment process, therapists cannot be expected to speak all the languages of their patients or to know the migration-specific, disease-specific and cultural aspects of each of their patients. However, they should possess knowledge and understanding of intercultural competence so as not to slip into stereotyped thinking (Schouler-Ocak 2000).

A nationally representative survey, carried out in 2008 on the utilisation of PIA services by patients with a migration background, found, as mentioned above, that this population group represented 32.5 % of PIA patients, a larger percentage than their representation in the overall German population. Additionally, on average, they were younger and had more children than patients without a migration background. Neurotic, stress-related and somatoform disorders were diagnosed with a significantly higher frequency among patients with a background of migration than among those without such a background (Schouler-Ocak et al. 2010).

In 2012, Berlin had around 3.38 million inhabitants, of whom 12,084 had an uncertain residential status. Of these, 2,643 had applied for asylum and were still waiting for the official decision about their desire, and 9,441 were required to leave the country – for example, due to the fact that their applications for asylum were already rejected officially. Together, they accounted for approximately 0.36 % of the population of Berlin (Federal Statistical Office 2012). Nationwide, 127,023 asylum applications were made in Germany in 2013, 24.9 % of which were recognised due to various legal requirements, 38.5 % of which were rejected and 36.7 % of which were decided (negatively) upon on the basis of formal criteria – such as Dublin II order – without a hearing.

Around three-quarters of asylum seekers thus remained in unsatisfactory, precarious living conditions and faced a lack of participation in social life if they do not leave the country (Federal Statistical Office 2012; Federal Office for Migration and Refugees 2014). This social insecurity increases the vulnerability and morbidity of people with a migration background. Heeren et al. (2014) found post-traumatic stress disorder (PTSD) rates of 41.4 % and 54.0 % among asylum seekers and refugees, respectively, and symptoms of anxiety and depression in 84.6 % and 63.1 % of the same groups. They concluded that mental health is significantly associated with residency status (Heeren et al. 2014). In other studies, high rates of mental disorders have been described among refugees, in particular PTSD, found in 20–40 % of the refugees, and comorbid disorders which often remain undiagnosed (von Lersner et al. 2008; Gierlichs 2003). Observations made in our PIA confirm these results.

When traumatised patients with a background of migration (primarily refugees and asylum seekers) attend their first appointment, often with an unclear insurance and residency status, they usually come across as apathetic, hopeless, lacking in drive and showing little affect. A detailed history is very difficult to collect at the beginning, and the patients very often report bodily symptoms such as physical pain or emotional states which conventional medicine does not always recognise as a known symptom of dysfunction (Pourgourides 2006). Schubert and Punamäki (2011) also documented this very clearly in Finland through their survey of 78 asylum seekers who had survived severe trauma such as torture; they observed that the secondary symptoms seemed to lead to either reports of psychiatric symptoms such as those of PTSD and depressive or anxiety disorders or complaints about physical symptoms, depending on the patient’s culture of origin. They concluded that depending on the person’s cultural background, the way symptoms of psychological distress manifested could be often misunderstood as physical illness in medical facilities of Western orientation (Schubert and Punamäki 2011), an issue that we also often observe in the career of our patients.

Before the actual therapy can begin, often a basic foundation for working together must first be created. Depending on the patient’s cultural and social background, it may not work, for example, if the treatment concept and planned treatment steps are not explained first. Subjects such as why regular medication is necessary, where to obtain this medication, how to register in the PIA and how punctual one must be to appointments all necessitate very different explanations depending on cultural background.

In most cases, it is just as important to help in making the alien environment more easy to understand, influence and manage. Sometimes, practical support from the social services department can be very beneficial for the patient. In individual cases, mental stabilisation can also be aided through practical support such as is sometimes offered through counselling centres; such support can enable the patient to find their way as far as possible in the new environment (Chu et al. 2013). Occasionally, it is possible to intervene usefully in the interests of the patient’s health in dealings with the appropriate authorities; in so doing, stressful living conditions can, for example, be improved. In most cases, the support of a lawyer is necessary; some patients need to have the asylum procedure explained so that those incalculable risks to which they are exposed can be made as controllable, predictable and transparent as possible.

In so doing, the foundations for therapeutic work together can be laid, and the stabilisation of the patient’s social situation can at the same time be supported. Now the actual therapeutic work can begin:

Patients who suffer from PTSD typically experience such phenomenon as flashbacks, vivid nightmares, free-floating anxiety, the feeling of being observed and restlessness. However, if we are talking about refugees with uncertain residency status, empirically, these symptoms cannot initially be treated because the stress experienced from day to day is clearly in the foreground. A stabilisation period of several months is required, during which effort is made to diminish the stress of everyday life to a minimum and in which those acute symptoms which are medically controllable are sought to be reduced. Drug treatments are usually necessary and effective in improving sleep quality or mood, and psychoeducation is necessary to cope better with some symptoms. In addition, nonverbal therapies such as those offered in our PIA – occupational therapy, sports and cooking groups – can be employed. Patients with a background of migration can usually be stabilised sufficiently within a few weeks such that further psychiatric diagnosis and therapy are possible.

It is often at this point that therapeutic work must be done on the patient’s hopelessness, anxiety, instability and suicidal tendencies, meaning that a considerable amount of time sometimes passes before a detailed anamnesis can be taken. Whereas the complete case history is not only important to bring the best treatment to the patient, it might be also important to help to prevent a rejection of the asylum application and therefore help to stabilise the social environment. This time delay can be very stressful, since in our experience, any support network the patient may have, lawyers or employees of the federal authorities, often has high expectations that detailed statements will be produced quickly in order to help in the asylum process.

As the therapeutic process continues, confusion, anxiety and feelings of helplessness may repeatedly recur, for example, if the authorities conduct an interrogation or the patient’s asylum application is rejected; symptoms will sometimes worsen consecutively (Haenel 2002). Some patients express a strong bitterness and lack of understanding about the fact that they are not allowed to work or to attend a German course and that going in contact with the native German people turns out to be so difficult. The goal of becoming a citizen with equal rights seems infinitely distant. Resentment is often expressed about having to stay in an assigned asylum centre, not being allowed to visit relatives and acquaintances outside the enforced residential districts and, occasionally, having to live in a different federal state than their spouse if they were unable to bring a marriage certificate when they migrated (Coffey et al. 2010). As part of the psychotherapeutic treatment, it is of course necessary to clarify these issues and to discuss the resulting feelings of resentment, despair and anger in order to develop coping strategies where necessary.

This therapeutic phase of stabilisation and support, aiming for at least partial reconciliation with a life situation which is usually precarious, socially unsatisfactory and deprived, with uncertain future prospects and often additional homesickness or concern about and missing of relatives, is slightly different than is seen in classic trauma-centred psychotherapy; it is upstream, so to speak. An actual ‘resource-oriented trauma psychotherapy’, as Reddemann (2002) describes it, is either not yet possible or only partly so, during this period of social instability in the host country which can be ongoing for several months and sometimes years. Only once external stability has been reached can the phases that are recommended by Reddemann be progressed through, namely, internal stabilisation, learning to have a healing relationship with one’s own body, confrontation with the trauma, acceptance and integration (Reddemann 2002).

If they are stabilised sufficiently to be prescribed specific trauma psychotherapy, traumatised patients who speak German can be sent to external outpatient disorder-specific psychotherapy; in recent years, this was possible after 2–8 months. Should more intensive treatment be required, the Centre for Intensified Psychotherapy and Counselling in Berlin at Charité University Psychiatric Clinic at St. Hedwig Hospital offers highly specialised and specific therapy services for German-speaking patients with trauma disorders.

Patients with a background of migration who speak insufficient German cannot participate in such treatment, and the ‘Treatment Centre for Victims of Torture’ Association in Berlin can see only a small percentage of them. Treatment or at least a reduction in the suffering of these patients, some of whom are seriously traumatised, is only made possible through mediated therapy with the help of an interpreter or professionally qualified translator (Schouler-Ocak 2014; Morina et al. 2010). For these patients, we have developed a specific therapy service, as follows.

As part of our PIA, we have developed a specialised multicultural interpreter-aided psychotherapy group, in which specialised group therapy takes place. This involves psychotherapeutic group therapy which is based primarily on mentalising and which takes place in alternation with psychoeducational elements and trauma-specific sessions. Alongside this, the patients also participate in outdoor activities in the local environment guided by an occupational therapist; these often allow patients to gain a whole new understanding of the culture and surroundings. In addition, patients who are particularly stressed or isolated are involved in other occupational therapy groups offered by the standard health-care providers.