[Current Outpatient Psychotherapeutic Care for People with Migration and Refugee Experience in Germany - An Overview]. / Die aktuelle ambulante psychotherapeutische Versorgung von Menschen mit Migrations- und Fluchterfahrung in Deutschland ­ Eine Übersicht.

Although mental health is a human right, even in a country with a well-developed healthcare system like Germany, it is not possible to ensure non-discriminatory access to mental health care for all people, regardless of their origin. For individuals with a history of flight or migration it is particularly difficult to gain access to adequate psychotherapeutic care. This review addresses key barriers contributing to the lack of outpatient care for people with a history of flight or migration. Lack of knowledge about the treatment system, fear of stigma, structural barriers, language barriers, lack of networking of healthcare providers, lack of knowledge of mental health practitioners, as well as stereotypes, discrimination, and racism towards people with a refugee or migration history were identified as the most important barriers with sufficient evidence. Innovative concepts such as peer support can enable non-discriminatory treatment access. In addition, there is an urgent need to train the profession of psychotherapists in racism- and discrimination-sensitive work and to integrate these aspects into psychotherapeutic education and training.

Low access and inadequate treatment in mental health care for asylum seekers and refugees in Germany-A prospective follow-up study over 12 months and a nationwide cross-sectional study.

Refugees experience elevated rates of mental health problems, but little is known about mental health service utilization and quality among asylum seekers and refugees in Europe. In a 12-month follow-up study of newly arrived refugees (N = 166, Mage  = 32.38 years, 30.7% female) and a nationwide cross-sectional study (N = 579, Mage  = 33.89 years, 36.2% female) of refugees who had been living in Germany for an average of 6 years, we examined objective need for mental health treatment, perceived need, access to treatment services, and adequacy of treatment. We defined minimally adequate mental health treatment according to the WHO World Mental Health Survey as ≥8 sessions of psychotherapy (minimally adequate psychotherapy) or pharmacotherapy plus ≥4 medical visits (minimally adequate pharmacotherapy). In both studies, two in three individuals screened for mental health symptoms and additionally perceived a need for professional treatment. Of those, less than half had contact to any service provider, with only 1 in 14 receiving minimally adequate psychotherapy. Overall, no more than one in seven of refugees in need received minimally adequate treatment. Despite a comprehensive mental health-care system, refugees' access to mental health care and the treatment provided are inadequate. Health policies are urgently needed to provide equitable mental health care for all.

The role of psychotherapists' perceived barriers in providing psychotherapy to refugee patients.

Access to psychotherapy is critical to improving mental health, but only a small proportion of refugees receive treatment in the regular psychotherapeutic care system in high-income countries. In previous research, outpatient psychotherapists reported several barriers to more frequent treatment of refugee patients. However, it is unclear to what extent these perceived barriers contribute to the poor provision of services to refugees. In a survey of N = 2002 outpatient psychotherapists in Germany, we collected data on perceived treatment barriers and on the integration of refugees into regular psychotherapeutic practice. Half of the psychotherapists reported that they do not treat refugee patients. In addition, therapies provided for refugees were, on average, 20% shorter than for other patients. Regression analyses showed direct negative associations between psychotherapists' overall perception of barriers with the number of refugees treated and the number of sessions offered to refugee patients, even when controlling for sociodemographic and workload-related characteristics. Correlation analyses on the level of specific types of barriers further revealed that particularly language-related barriers and lack of contact with the refugee population are negatively correlated with the number of refugees treated and the number of sessions for refugees. Our findings indicate that the integration of refugees into regular psychotherapeutic care could be improved by measures to connect psychotherapists with refugee patients as well as professional interpreters and to ensure coverage of costs for therapy, interpreters and related administrative tasks.

Welcome, how are you doing? - towards a systematic mental health screening and crisis management for newly arriving refugees.

Background: Compared to the general German population, refugees in Germany are a high-risk group for trauma spectrum disorders. Currently, many barriers exist for the implementation of a screen-and-treat approach for mental disorders as part of the routine health care provision during the early stage of the immigration process.Objective: The aim of the present study was to develop and test a systematic screening approach to identify individual refugees in need of mental health care during the initial immigration phase.Method: 167 newly arrived refugees underwent a screening interview with the Refugee Health Screener (RHS) carried out by Intercultural Therapy Assistants (ITAs). The ITAs were super-vised by psychologists at a reception centre in Bielefeld, Germany. A subsample of 48 persons partici-pated in clinical validation interviews.Results: Findings demonstrated the need for and feasibility of a systematic screening during the initial immigration phase. However, established cut-off values of the RHS had to be adapted and the screening procedure had to be adjusted due to the needs of a significant number of refugees in severe psychological crises.Conclusion: A systematic screening that is applied shortly after arrival facilitates the early identification of refugees at risk of developing mental disorders and may be helpful to prevent chronic symptom development and an aggravation of psychological crises.

A systematic complementary screening procedure during the initial immigration phase was found to be useful for the identification of refugees in need of mental health care.The procedure could be implemented both safely and efficiently in conjunction with the initial medical check-up for recently arrived refugees.Responding to the needs of the refugees immediately following their arrival in Germany, we adjusted the cut-off of the screening instrument and suggest to explicitly include a detection procedure for severe psychological crises.

Externalizing problems mediate the relation between teacher and peer violence and lower school performance.

BACKGROUND: The association between children's exposure to family violence and poor academic outcomes is well-established. Less is known about how exposure to violence in the school context, i.e., by teachers and by peers, affects academic functioning. Moreover, the role of children's mental health problems in this link has hardly been examined. OBJECTIVES: We examined direct and indirect associations between children's experiences of violence by teachers and peers and children's mental health and school functioning while controlling for children's experiences of parental violence. PARTICIPANTS: Using a multistage random sampling approach, we obtained a representative sample of 914 students (50.5 % girls, Mage = 12.58 years) from 12 primary schools in Tanzania. METHODS: In structured interviews, students' experiences of violence and mental health problems were assessed. Students' academic performance and absenteeism were documented using school records. Associations were examined using structural equation modeling. RESULTS: Experiences of more teacher and peer violence were each significantly associated with higher externalizing problems (teachers: ß = 0.27 [95 %-CI: 0.12, 0.47]; peers: ß = 0.17, [95 %-CI: 0.07, 0.32]). Higher externalizing problems were significantly associated with poorer academic performance (ß = -0.13, [95 %-CI: -0.23, -0.02]), implying significant indirect associations between students' experiences of teacher violence (ß = -0.04, [95 %-CI: -0.08, -0.01]) and peer violence (ß = -0.02, [95 %-CI: -0.05, -0.01]) and their academic performance via externalizing problems. CONCLUSION: Exposure to violence at school may impair children's academic performance indirectly by increasing attention and behaviour problems. Further investigations in longitudinal studies and implementation of interventions to reduce violence in schools are indicated.

Othering refugees: Psychotherapists' attitudes toward patients with and without a refugee background.

Objective: A large proportion of refugees present with psychological disorders that require psychotherapy as first-line treatment. However, even in countries with well-established psychotherapy system, refugees continue to face barriers to care. Psychotherapists' attitudes toward refugees may also impede access to psychotherapy, as it is evident that stereotypes of health professionals contribute to health care disparities. However, little is known about psychotherapists' attitudes toward refugees. Methods: In a cross-sectional online study of N = 2002 outpatient psychotherapists in Germany (Mage = 54.48 years, 73.1% female), a vignette experiment was applied to examine differences in therapists' attitudes toward refugee patients from the Middle East and non-refugee patients. Subsequently, associations between attitudes and psychotherapists' characteristics (e.g., provision of treatment for refugees) were analyzed. Results: Results showed significant differences between therapists' attitudes toward refugee and non-refugee patients (ηp2 = .23), with more therapy-hindering attitudes toward refugee patients. Higher therapy-hindering attitudes were significantly associated with less frequent provision of psychotherapy for refugees. Conclusion: Our findings provide initial evidence that psychotherapists perceive refugee patients as deviant from the norm and that these divergent attitudes may relate to disparities in mental health care. To avoid such a process of othering, training for psychotherapists should question stereotypes toward refugees.

The role of violence perpetration in driving externalizing problems and offending behavior among youth from eastern Democratic Republic of Congo.

Youth in conflict-affected regions are exposed to a multitude of traumatic events. These individuals often witness violence; experience it firsthand; and, in some cases, become perpetrators. The interplay of events shapes systematic trauma histories that may have unique implications for youths' mental health. In a cross-sectional study conducted in eastern Democratic Republic of Congo (DRC), we interviewed 295 war-affected youth (63.4% boys, Mage = 16.70 years), including former child soldiers (n = 171), regarding their traumatic experiences and mental health. Using latent class analysis, we identified four common trauma history classes categorized by (a) low exposure, (b) medium exposure, (c) high exposure, and (d) high exposure/perpetration. Across the sample, gradual increases in trauma load corresponded with increased vulnerability to posttraumatic stress disorder (PTSD) symptoms, ηp 2 = .36, and internalizing problems, ηp 2 = .12; however, only youth from the high exposure/perpetration class differed significantly from other youth in their levels of externalizing problems, ηp 2 = .13, and offending behaviors, ηp 2 = .17. A longer time in armed groups was related to a higher risk of both experiencing and perpetrating violence. The results indicate that it is not child soldier status, per se, but the perpetration of violence that reinforces a cycle of violence in conflict-affected societies by contributing to increased externalizing problems and offending behaviors. In conflict regions, integrated approaches are needed to address both trauma and externalizing problems of war-affected youth.

Mental health problems moderate the association between teacher violence and children's social status in East Africa: A multi-informant study combining self- and peer-reports.

School victimization has been negatively associated with children's social status. However, previous studies have primarily focused on peer victimization, leaving a significant knowledge gap regarding violence by teachers. We hypothesized that, when almost all children experience violence by teachers, not only the experience of violence, but also other factors, for example, mental health problems, may influence children's social preference and centrality. We therefore examined potential moderation effects of children's internalizing and externalizing problems. We implemented a multistage cluster randomized sampling approach to randomly chose fifth- and sixth-grade students from primary schools throughout Tanzania. Using a multi-informant approach, data were collected from 643 children (51.0% girls, Mage = 12.79 years). Results showed inconsistent direct associations between teacher violence and social status, whereas mental health problems were consistently associated with lower social status. Significant interaction effects were found for internalizing problems; that is, teacher violence was associated with lower social status for increasing internalizing problems. However, no interaction effects were found for externalizing problems. The findings underline the burden of exposure to violence by teachers and the importance of mental health for children's social functioning. Knowledge about interrelations can be applied in interventions to effectively reduce violence by teachers toward students.