From the Couch to the Community: The Emergence of Peer-to-Peer Therapy for Refugees in Switzerland
This is part of our special feature on forced migration, Narration on the Move.
Since 2016, millions of individuals have fled the Middle East and Northern Africa and have entered the European Union (EU) through Italy, Greece, and Spain. Although the majority of refugees seek asylum in Germany, a considerable minority of individuals seek protection in Switzerland. Per capita, Switzerland has among the highest numbers of refugees seeking asylum, although the numbers have been decreasing in recent years due to shifts in geopolitics, legal frameworks, and route closures. Petitions for asylum are sought for a myriad of reasons, including political conflict, ethnic persecution, poverty, and exposure to chronic violence. Given the stressors associated with migration, it is not surprising that a very high number of asylum seekers in Europe in general, and Switzerland in particular, exhibit stress-related mental health issues such as posttraumatic stress disorder (PTSD) as well as depression, somatic complaints, and substance abuse.
For four weeks this summer we conducted research in Switzerland aimed at better understanding mental health issues that asylum seekers might face and to learn about how practitioners and researchers are addressing these issues. What emerged from our work is the notion that the best way to reduce the major mental health burdens experienced by asylum seekers is not through specialists, such as psychiatrists and clinical psychologists. Instead, treatments are looking to train lay members of refugee communities to take on the role of a mental healthcare provider. Although this may seem like a somewhat simple idea, in some ways, it signals a broader reckoning and radical reorganization in psychiatry, psychology, and allied fields. There has been great debate concerning mental healthcare delivery, centered around how and by whom care is delivered. Interest in decentralizing mental health work is no small matter, as there is some evidence to suggest experts feel anxious about their relevance among increasingly peer-driven treatments. Apprehension regarding this shift in mental healthcare delivery is due in part to concerns about capability and adequate training of personnel, potential preference for non-professionals, and fragmentation of service provision.
While there will always be a need for specialists to provide care for chronic and acute cases of mental health issues, there is a rapidly growing belief that what many asylum seekers need to help manage migration-related stress is education about mental health and the potential negative effects of adversity and trauma, a strong social support network, and concrete skills to help address mental health problems as they emerge. Over the past few years, organizations such as the World Health Organization (WHO) have created a series of manual-based treatments that can be taught to people with, in some cases, little to no background in mental health training. This is a framework often referred to as “task shifting.”
The case for task shifting in Switzerland and perhaps throughout the EU is strong. Meta-analyses are showing that approximately 30% of refugees may be experiencing mental health issues, and numerous papers indicate disparities in care. We interviewed a doctor working at an Asylum Center in Bern who reported that approximately 9 out of 10 individuals in the asylum center exhibit symptoms of depression. During a visit to the asylum center, over the course of a day every patient we met requested to speak with a psychiatrist. Some of these individuals may have requested a psychiatric referral in part because they were told it would increase their chances of obtaining asylum status, however many also needed psychiatric care. The two possibilities are not mutually exclusive.
We learned that although some asylum seekers may get rapid access to a mental health professional, such as in clear cases of domestic violence, treatment for mental health issues related to migration can take considerably longer. Numerous interviews conducted with specialists at the University of Bern and Zurich, WHO, UNHCR, and asylum centers, as well as desk research, indicated that there are many barriers to care. Like many high-income countries with many extremely well-trained professionals, Switzerland is not effectively treating highly vulnerable patients whose prognosis may be affected as a result of long wait times and delays. Multiple factors contribute to long wait times: refugees may not understand the healthcare system or trust medical providers, there may be stigma in refugee and other Swiss communities around mental health treatment, and the health system, in turn, may not have adequate translation services. Doctors may also hold prejudices against migrant individuals. There are signs that efforts are being made to address these issues both politically and clinically: for example, the rise in hospital-based translation services available to doctors and the inclusion of mental health in the United Nations’ (UN) Sustainable Development Goals.
There is hope that a shift toward peer-to-peer care may be a radical way to improve mental healthcare. This is in light of the scale of mental health problems among forced migrant communities, the disproportionately small workforce of highly trained mental health clinicians, and the socio-cultural barriers that underlie patient-practitioner relationships. Depending on the intervention, non-specialists with similar lived experiences (“peers”) are taught a series of modules that they can employ to help support their community members. Supporters of the task-shifting approach point to the many obvious potential benefits, such as: reducing language barriers and a greater understanding of the issues faced by the person seeking care.
There is a growing body of research showing that peer to peer treatments are effective for individuals living in low and middle-income countries despite their being relatively new. Several studies with refugees and asylum seekers have also found that peer-to-peer therapy can lead to a significant reduction in symptoms. There is a cautious sense of optimism about the benefits of peer-to-peer and a number of programs are starting. The Strengths Program, led by Dr. Naser Morina, from the University of Zurich, is training Syrian refugees in a WHO treatment called Problem Management Plus. This program is designed to support individuals suffering from distress following exposure to significant adversity. Another group is adapting a peer-to-peer model from Germany that they hope to launch in Switzerland this year. Other studies have shown that peers with asylum seeker status who participated in health awareness- targeted at promoting understanding of mental health including knowledge of risk and protective factors- also benefited from such experiences, reporting a greater sense of empowerment and ability to increase their professional network.
Caution must be applied to the task-shifting approach. Without consistent and sufficient resources, those responsible for delivering care will not have adequate ongoing training and support. Mental healthcare is very demanding and without proper support, we risk placing great burdens on highly vulnerable communities. Moreover, more studies are needed; although the data is promising, additional research is necessary to understand the efficacy of these treatments in different contexts. Furthermore, more work is needed on how these mental health interventions connect to ongoing cultural, social, legal, stressors in one’s post-migration context. For instance, peer-to-peer treatments may be effective not only in helping to change perceptions of one’s psychological symptoms, but could also serve as a critical tool for connecting people to legal services, political organizing, and educational opportunities- all of which would have positive mental health effects.
It is clear that unless we radically rethink how we develop and deliver mental health care in the context of forced migration, many people will not receive much-needed support and care. The research that we conducted this summer revealed the complex ways in which policymakers, practitioners, researchers, and healthcare providers are trying to reorient, realign, and retrain in ways that not only shift who is delivering the care but, critically, have the potential to create important spaces for communities affected by forced migration to take a leading role in mental healthcare. For a field whose history is shaped, in part, by its poor and sometimes inhumane treatment of patients, the notion that specialists are working alongside vulnerable communities to develop and implement new forms of mental healthcare may have political impacts that ripple well beyond the waiting room.
Adam Brown is a clinical psychologist and Associate Professor at The New School for Social Research, where he directs the Trauma and Global Mental Health Lab. He is also an Adjunct Assistant Professor in the Department of Psychiatry at New York University School of Medicine. This article reflects the work that he did this summer in Switzerland through the Consortium on Forced Migration, Displacement and Education, in which he and Alexa Elias (Vassar College), Dayveliz Hernandez Mustafa (Bard College), Nicole Kormendi (Vassar College), Anamaria Alvarez (Bard College), Brooke Prakash (Sarah Lawrence College), Sanjana Conroy-Tripathi (Sarah Lawrence College), McKenna Parnes (Suffolk University), and Julia Superka (New School for Social Research) conducted research on migration and mental health.
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Published on October 29, 2019.