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OBJECTIVE: Refugees and asylum seekers are highly vulnerable to the development of mental health problems, yet oftentimes their need is underestimated. We aimed to develop a culturally sensitive screening tool for primary care settings assessing the urgency and need for mental health treatment to close this gap. METHOD: Items for the screening tool were selected out of an item pool generated by a group of clinical experts based on the data obtained from n = 307 asylum seekers in a refugee state registration and reception center in Germany. Out of these, n = 111 attended a psychosocial walk-in clinic, and clinicians' ratings of urgency and need for mental health treatment were added. RESULTS: The resulting questionnaire comprised 8 items assessing urgency and 13 items assessing need for mental health treatment. Sensitivity was =0.74 and specificity =0.70. Participants of clinical and non-clinical samples differ highly significantly (p < .001). Cross-cultural validity was shown by comparing measurement invariance for different countries of origin. CONCLUSION: The RAS-MT-Screener is a clinically and cross-culturally valid screening tool in primary care settings for the urgency and need for mental health treatment with acceptable psychometric properties. Future research on its external and construct validity is warranted.

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Background: Asylum seekers are a particularly vulnerable population due to a wide range of external stressors. Traumatic events and difficult social/economic prospects can lead to an elevated susceptibility for substance use disorders. The aim of the present study was to determine whether asylum seekers suffering from mental or physical distress present higher levels of substance use disorder (SUD) in a state reception center in Germany and whether there are identifiable risk or protective factors. Methods: We performed a hierarchical logistic regression on data of N = 238 people who had applied for asylum in Germany to analyze the SUD variance explanation by (1) sociodemographic, (2) flight-specific, and (3) psychometric (ERQ, SOC-9 L, SCL-K9) variables. On level (4), we included the location of data collection (walk-in clinic or accommodation,) as an indicator of individual's need for a psychologist's or General practitioner's help in order to assess for the participant's (mental) distress. Results: Low educational level, lower sense of coherence, and mental distress (location of data collection in the psychosocial or general medical outpatient clinic) were associated with SUD. Those suffering from SUD seemed to be less aware of external stressors as SUD was also associated with low levels of reported post-migratory stress. Discussion: The association of SUD with psychological distress and lower education reaffirms the concept that some vulnerable groups are at a higher risk for substance-related difficulties. Strengthening the sense of coherence with targeted interventions might enable at-risk groups to cope better with forthcoming burdens and help with abstaining from current or future consumption.

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Due to pre-, peri- and post-migratory stress factors, refugees often experience higher levels of psychological stress than the general population. Post-traumatic stress disorder, in particular, has an increased prevalence in the refugee population. However, living conditions in the early post-migratory phase are characterized by many challenges. In the present qualitative study, 14 refugees with symptoms of PTSD from temporary accommodations in Germany were interviewed in semi-structured interviews about their individual experiences of the impact of their trauma sequelae symptoms on their current living conditions and interactions. Participants reported dealing with post-traumatic symptoms primarily through distraction strategies, such as working or learning the language or social interaction. Many reported a sense of mistrust as a result of traumatic experiences. Current stress factors cited included uncertain asylum status, worry about family members and lack of ability to influence living situations. The interactions between the post-traumatic symptoms and the living conditions of the refugees were highlighted. The effects of the symptomatology of trauma sequelae and the framework conditions under which refugees live can lead to aggravated psychological distress. Therefore, special attention must be paid to refugee mental health care.

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OBJECTIVE: Due to pre-, peri-, and post-migration stress factors, the prevalence of mental illnesses among refugees is higher than in the average population. To survey the prevalence of symptoms of posttraumatic stress disorder, depression and anxiety disorder among refugees who have been living in Germany for a longer period of time in a low threshold manner, a study with short questionnaires in temporary accommodations in the Rhine-Neckar region was conducted. METHODS: To determine the prevalence of psychological stress symptoms, all adult refugees in 7 temporary accommodations in the Rhine-Neckar region were approached. If they agreed to participate and spoke one of the 7 available languages, psychological stress was assessed using PC-PTSD-5 and PHQ-4 (n=106). RESULTS: On average, the participants experienced 3.18 (SD 2.48) traumatic events. 47.2% showed symptoms of posttraumatic stress disorder, 37.7% of depression and 29.2% of anxiety disorder. Neither gender nor age was significantly related to certain traumatic events or the diagnoses mentioned. DISCUSSION: This study shows a high prevalence of traumatization and psychological distress among refugees that have been living in Germany for several months or years. However, both the identification of affected persons and mental health care is associated with numerous challenges. CONCLUSION: Even after a longer stay in Germany, the prevalence of psychological distress is significantly higher in both genders and across all age groups compared to the general population. There is a great need to identify mentally ill refugees systematically and to close existing gaps in mental health care.

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Pregnant refugees and new mothers are at high risk of developing mental health problems. Previous research has highlighted an increase in adverse pre-, peri- and postpartum outcomes in refugee women and their newborns. This descriptive study aimed to present the characteristics and needs of refugee women who attended a psychosocial walk-in clinic addressing pregnant refugees' and new mothers' maternity mental healthcare needs in a state registration and reception centre in Germany. We assessed all patients that consulted the clinic and received interventions during the first 28 weeks after it opened, collecting information on symptoms, diagnoses, attitudes towards and experience of pregnancy, birth, obstetric care and applied psychosocial interventions during consultations. Between November 2017 and May 2018, N = 120 pregnant refugees and new mothers attended the clinic. Most patients were diagnosed with post-traumatic stress-, adjustment- or depressive disorder. While 69.6% of the women reported physical and mental health problems during pregnancy, 87.4% experienced obstetric complications. Trauma-informed and psychoeducational interventions were primarily used during counselling sessions. Our data underpin the glaring disparities in refugee maternal healthcare in Germany. Maternal care designed to meet the specific needs of pregnant refugees and mothers is essential. More targeted, evidence-based and cost-effective interventions are needed. Our psychosocial walk-in clinic is a first step towards ensuring primary care delivery for refugee women during the particularly vulnerable period of pregnancy and early motherhood.

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Female refugees are frequently exposed to sexualized, gender-based violence and harassment before, during, and after their flight. Yet female refugee-specific care and protection needs are rarely addressed in host countries. This study aimed to evaluate a mother and child center (MUKI) for female refugees in a reception and registration center in Germany. In 2017, we conducted semi-structured qualitative interviews with 16 female refugees attending the MUKI and with its five main staff members. We asked the participants about the MUKI's relevance, encountered difficulties, and suggestions for improvement. The interviewees appreciated the MUKI's sheltered environment, care services, and socializing opportunities, as well as its women-only concept. Overall, the participants saw overexertion, social engagement-related difficulties, and the MUKI's noisy environment as key attendance barriers. Interviewed staff primarily reported problems regarding the working conditions, including the high staff and attendee turnover and low general service awareness. The participants advocated an expansion of the MUKI program. The MUKI project underlines that providing newly arrived, vulnerable female refugees with sheltered surroundings and psychosocial services is an essential step toward addressing female refugees' specific care needs.

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Providing refugees with psychosocial support is particularly important considering the high level of mental health problems prevalent in this population. A psychosocial walk-in clinic operating within a state reception and registration center in Germany has been supporting mentally burdened refugees since 2016. This study focused on patients' perspectives on their mental health burden, the psychosocial walk-in clinic, and future help seeking. We conducted interviews with n = 22 refugees attending the walk-in clinic from March to May 2019. Qualitative analysis focused on the following four topics: (1) mental burden from the patients' perspective, (2) access to the psychosocial walk-in clinic, (3) perception of counseling sessions, and (4) perception of follow-up treatment. The results show that the majority of interviewees were burdened by psychological and somatic complaints, mostly attributed to past experiences and post-migratory stress. Therapeutic counseling and psychiatric medication were found to be particularly helpful. Most of the participants felt motivated to seek further psychosocial support. Key barriers to seeking psychosocial help included shame, fear of stigma, and lack of information. Overall, the psychosocial walk-in clinic is a highly valued support service for newly arrived refugees with mental health issues.

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Refugees are often exposed to a variety of stressors and traumatic events, posing a significant risk for the development of mental disorders. Young refugees may be particularly at risk because adverse life events affect identity formation, a developmental task that is typically expected in adolescence and emerging adulthood. Trauma and cultural changes may alter identity development, potentially leading to identity diffusion, a core concept of personality disorders. However, previous research on personality pathology among refugees is scarce. In this study, we examine identity development and maladaptive personality traits in young refugees and migrants. Refugees from 22 countries of origin were recruited in a German reception center (n = 120) and a group of adults with a migration background in first- or second generation was obtained via web-based recruitment (n = 281). Identity development was measured using the Assessment of Identity Development in Adolescence - Short Form. Maladaptive personality traits were assessed with the Personality Inventory for DSM-5-Brief Form. Group differences between refugees and migrants regarding identity development and trait expression were investigated using t-tests. The relationship between the two measures and their corresponding subscales was examined by means of correlation analyses. Refugees reported significantly higher levels of identity diffusion, negative affectivity, detachment, antagonism, and disinhibition compared to migrants. No significant differences were found for psychoticism. Correlation analyses revealed low to moderate positive associations between identity diffusion and maladaptive trait expression. Possible implications for early phase of resettlement, preventive psychiatric care and further research questions are discussed.

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BACKGROUND: Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees' emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings. OBJECTIVE: This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany. METHODS: From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone. RESULTS: At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique "The Inner Safe Place" was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations. CONCLUSIONS: The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, "The Inner Safe Place" technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.

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OBJECTIVE: In the medical and psychosocial health care of refugees the use of interpreters is of fundamental importance. The involvement of interpreters changes the dyadic practitioner-patient system to a triad requiring different behavior guidelines. The aim of the present study was to evaluate the involvement of interpreters in the medical and psychosocial outpatient clinic in a registration centre for refugees in the state of Baden-Württemberg. METHOD: For a general overview of the use of interpreters in different types of consultation hours and a comparison of the local practice with guidelines from the literature, a systematic survey was conducted in N=75 treatment cases with N=19 practitioners, N=27 interpreters and N=75 patients using an observation sheet. Among the factors studied were sitting positions in the triad, the manner of translation by interpreters, eye contact and orientation of speech of practitioners and patients towards each other during the phases of linguistic production, the interaction with family members and the occurrence of briefings or meetings after the consultation. RESULTS: Results show that the observed interpreters were almost exclusively non-professionals without qualification for this profession. Interpreters translated according to the so-called black box model or predominantly self-initiated as co-therapists and usually did not act as references of cultural aspects. Furthermore it could be observed that practitioners oriented the communication - eye contact and direct speech - primarily towards interpreters, not to patients. In addition, there was no briefing between the therapist and the interpreter or meeting after the consultation in any of the consultation hours surveyed. CONCLUSION: The practice of involving interpreters differs from guidelines of research literature. The present study uncovers these discrepancies and thus has implications for the work of practitioners and interpreters in refugee care.

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Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.

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Background: Due to persecution, human rights violations and armed conflicts, the prevalence of post-traumatic stress disorder (PTSD) is high in refugee populations. Previous studies indicate that trauma-focused treatments are highly effective in treating PTSD in refugees. However, these approaches rely on the stability of the therapeutic setting, treatment continuity, and safe housing. Although early treatment of PTSD is recommended, these requirements are not met in reception centers. Therefore, we conducted a pilot study to examine the effect of imaginative stabilization techniques derived from psychodynamic psychotraumatology therapy for the early stabilization of traumatized refugees in a reception center. Methods: From May 2017 to April 2018, 86 imaginative stabilization group therapy sessions have taken place. A sample of 43 out of 46 traumatized refugees completed self-report questionnaires assessing PTSD, depression, and anxiety symptoms prior to attending open imaginative stabilization group therapy sessions. Furthermore, participants filled in self-report questionnaires on distress and emotional state (valence/arousal/dominance) before and after each session. After having participated in four consecutive sessions, a sub-group of 17 participants completed a follow-up assessment of PTSD, depression, and anxiety symptoms. Follow-up interviews were conducted with 25 participants 2 weeks after their last session attendance to explore self-practice habits post intervention. Results: The pre-post-intervention comparison of scores indicated a significant reduction of distress (z = -3.35, p < 0.001, r = -0.51) and an improvement of affective reports for valence (z = -4.79, p < 0.001, r = -0.82) and dominance (z = -3.89, p < 0.001, r = -0.59), whereas arousal scores were not affected. We found a significant reduction of anxiety symptoms (z = -2.04, p < 0.05, r = -0.49), whereas PTSD and depression scores remained unchanged. Follow-up interviews revealed that 80% of the participants continued to practice the imaginative stabilization techniques after redistribution to other accommodation. Conclusion: The results indicate that imaginative stabilization techniques are a promising and feasible approach to treat refugees in unstable reception center settings. In regular imaginative stabilization group therapy sessions, we were able to reduce the participants' distress and anxiety symptoms while strengthening their internal resources and increasing their emotional stability.