Mr. Diab, what services are available for refugees at Zentrum ÜBERLEBEN?
Our therapeutic services - the day clinic, the outpatient department for adults, and the children's and adolescents' department - are meant for refugees who have experienced torture, persecution, war, or human trafficking in their home country or during their flight, and as a result have suffered psychological distress in the form of trauma and trauma-related disorders.
In turn, the Paulo Freire Vocational School and the Department for Refugee Assistance can serve a much broader group of migrants and refugees. Language and computer courses, school-leaving qualifications, vocational preparation courses, and training and further education are offered there.
In addition, we offer low-threshold services such as the specialist office of the Berlin Network for Vulnerable Refugees. The network includes seven organizations in Berlin that carry out an initial diagnosis and determine the special need for protection for LGBTIQ+ people, people with disabilities, women, pregnant women as well as minors, among other things. The specialist office at the centre in this frame is the contact and counselling centre for traumatized people and victims of severe violence.
A diverse Team is the key to success
Which countries do your patients in the day clinic come from?
People from all crisis areas of the last 30 to 35 years that are within reach of Europe find their way to us. For example, from the sub-Saharan region, West and East Africa, the Middle East, Asian countries such as Azerbaijan, Turkmenistan or Afghanistan, and the Balkans. Last year, we had a significant increase in requests from Afghanistan and Iran, understandably because of the Taliban takeover and protests in Iran. Such events have a direct impact on our work. Currently there are also many requests from refugees from Turkey.
"Word-for-word translation is only part of their job"
Refugees who are treated in the day clinic usually speak different languages and come from different cultures and political contexts. How do you and your colleagues adjust to this?
We are pretty diverse team. While this can improve even more, we have colleagues that come from Africa or Asia, colleagues that speak French, Farsi or, like myself, Arabic as their mother tongue. This offers a variety of starting points for our patients.
Likewise, the colleagues who grew up here contribute a lot to the treatment concept with their experience. But most of all, our language and cultural mediators are of enormous importance: the word-for-word translation is only one part of their work. Sometimes, as a therapist, one has the feeling that something remains hidden, which can have linguistic or cultural reasons. The language and cultural mediators know how things are expressed or addressed in the respective countries and they are able to read between the lines. This helps to understand what is going on in the patient's mind.
Trauma sequelae disorder – the danger of splitting
How difficult is it for your patients to talk about their problems?
Most struggle to put their experiences into words. This is to do with the traumatic experiences themselves on the one hand and the way traumatic experiences are processed on the other. Central here is the notion of splitting. When we experience something horrible, our psyche tries to protect us by splitting off and pushing aside troublesome things to ensure survivability in such a threat scenario. This is a sensible process in order to survive the threat.
But when the threat is over and there is no success in integrating the experiences into the rest of the psychological events, the splitting off remains. The risk of developing trauma sequelae disorder in the sense of post-traumatic stress disorder is then very high.
“Images that are so powerful that the person feels like they are reliving the trauma”
What are the symptoms associated with post-traumatic stress disorder?
A central symptom is hyperarousal. People are in a state of permanent tension towards their environment. Every noise, every movement or stress from outside can quickly lead to sensory overload.
The re-experiencing is a second, very important factor. Triggered by a key stimulus, the traumatic experience returns and controls the sufferer's perception. The most common form is flashbacks. These are images so strong that the person feels that he or she is reliving the trauma or parts of it, sometimes even accompanied by the physical pain associated with the original torture. The images can occur while awake and in the form of nightmares.
Another symptom is avoidance behavior: Due to the inundation of stimuli and flashbacks triggered by everyday life, affected individuals tend to avoid situations that could evoke memories of the trauma. This significantly affects people's everyday lives and, in some cases, can lead to complete isolation.
To what extent do the mental ailments make themselves felt physically?
Repressed trauma material and the associated emotional states that have not been processed or expressed in a timely manner can quickly result in physical ailments. Many struggle with back pain or headaches.
"Regaining trust in the sovereignty of one’s own body”
In addition, the perception of one's own body may be disturbed. After all, we are talking about a body that has experienced an assault in the sense of torture, human trafficking or sexualized violence. Especially in the case of sexualized violence, the body is often perceived as something shameful, vulnerable and repulsive and not as something lovable and enjoyable.
Regaining trust in the sovereignty of one's own body and experiencing anew the mutual positive influence of psyche and body can contribute a lot to a successful therapeutic process. For this reason, about one third of our therapy offers are body-related. Examples of this are mindfulness training, dance therapy, sports and relaxation techniques
Methods and means of Zentrum Überleben
Why is the focus in the day clinic on group therapies?
People whose complaints are chronic and who can no longer cope with everyday life come to us in the day clinic. Building trust and dealing with other people is a major challenge for many. Group services have the advantage that difficulties can be experienced on site and direct intervention is possible. What people experience outside in everyday life they also experience in our groups, except that here they are accompanied therapeutically and are in a protected space.
When problems arise, there is an opportunity to try things out and explore new avenues. Our services can be roughly divided into body-based, creative and speech-based therapies. In addition to the group therapies, we offer individual sessions with therapists, physiotherapy and social work sessions. Especially the meetings with the social workers are very important, because our patients are not only struggling with psychological stress, but also with the challenge of being in a country where they do not know how everything works.
How do refugees find their way to Zentrum ÜBERLEBEN?
Most patients are referred to us by their first aiders in their shared accommodation. Hospitals, outpatient clinics, colleagues in private practice, counselling centres or semi-professional support systems also send many people to us. It also happens that people who speak English find us on the Internet. Some of them find us through the community.
"Anyone who has health insurance can be treated at our clinic"
How does the centre finance itself?
Each department has its own concept and funding. The day clinic currently has 24 places. We are relatively well positioned because we are financed by the health insurance funds. Anyone who has health insurance can be treated at our clinic. That doesn't cover our costs, but it covers a good part of them.
Other areas, such as the outpatient department, are financed in a mixed way by the Association of Statutory Health Insurance Physicians, project funds and donations. Zentrum ÜBERLEBEN has a budget of 8 million euros, and this comes from all kinds of sources: the federal government, the state, health insurance companies, districts, the Association of Statutory Health Insurance Physicians, private individuals and so on. That doesn't exactly make things easy.
Poor psychosocial care in rural areas
The psychological care needs of refugees in Germany are far from being met. What needs to change from your point of view?
We are better positioned in Berlin than in any other federal state, but even here the situation is often precarious. If you look outside the city, the situation is even disastrous in some cases. There are entire landscapes where there is no provision for refugees. Due to the language barrier, many opportunities remain closed to these people.
This is where the legislator is needed. For years it has been pointed out that the right to treatment does not end with the infrastructure and the availability of doctors, therapists and nurses, but that mediation is also part of it. The costs for interpreters are still not covered. There must be a change in the law so that the health insurance companies cover these costs.
"The focus should rather be on how we can create a pluralistic society with all these differences, but also clear boundaries"
These grievances do not only affect the psychiatric and psychotherapeutic field. There are many diseases that are overlooked and thus remain untreated. We often diagnose high blood pressure, diabetes and infectious diseases along the way. This goes completely under the radar because people don't have adequate access to the healthcare system.
How do you feel about the image of refugees conveyed by the media in light of the stories you are confronted with every day?
I find the reporting in the media to be very one-sided. It does not do justice to the complexity and diversity of this group. My personal impression is that integration is shifted onto those affected. The accusation that they don't integrate and abide by the rules often resonates within reporting.
I understand integration differently. Integration is a joint process. In my view, however, the main responsibility lies with the political decision-makers and not with those who are "stranded" and isolated here. Politics has missed out on a few things here.
The political discourse should not be about all migrants and refugees becoming Germans. The focus should rather be on how we can create a pluralistic society with all these differences, but also clear boundaries. From my experience as a therapist working with very diverse groups, I can say that this can indeed work.
This article was also published in German