In 2015, shortly after Amadou, a fifteen-year-old Guinean boy, had arrived in Switzerland on his own after harrowing journeys across African bush, desert and Mediterranean seas, he was hospitalised for life-threatening depression, suicidal behaviour, and severe bouts of psychosis.
Just five years later, in 2020, his life is strikingly different. He has made many friends, goes to work every day, and can afford to live in his own flat.
He says the reason for the turnaround is the psycho-social support that he received, based on a model for mental health services tailored to migrant groups and ethnically diverse populations - known as “transcultural psychiatry”. The Swiss version has been pioneered by a group of Lausanne-based clinicians in collaboration with a Lausanne-based NGO known as Appartenances, and their approach has become a model throughout Europe.
“My psychiatrist saved my life,” says Amadou. “Before him, I wanted to commit suicide, and without him, I would not be speaking with you right now.
“My doctor is almost my friend, he is part of my life. If I had to tell you everything he’s helped me with, we would end up speaking all night. He helped me find a job, get my driver’s license, and most importantly, he gave me the courage to call my mother for the first time in three years.”
Why mental health, especially in migrants, matters. Amadou’s story reflects the difference mental health support can make for international migrants when they finally hit European soil. Even as coronavirus-imposed restrictions batter mental health services around the world, such services are more important than ever for migrants who lack the usual family and community support systems.
Just last week, WHO released its first survey of migrant mental health during Covid-19, which finds that over half of those surveyed struggle with depression, worry, anxiety, and loneliness. The survey, based on self-reports from some 30,000 migrants around the world, collected in over 30 languages, also revealed that migrants were less likely to access healthcare, mainly as a result of financial constraints and fear of deportation.
Switzerland, the country with the largest per-capita share of migrants in the whole of Europe, is no exception. There is “clear evidence” that some migrant populations, especially refugees and undocumented migrants, struggle to enjoy a quality of mental health comparable to the rest of the Swiss population, said Denise Efionayi of Neuchatel University, who co-authored the country’s most recent report on migration.
Despite these massive disparities in health, local tools that could bridge the gap, including culturally appropriate psychiatry services, are not yet mainstream - even though NGOs such as Appartenances have operated for over two decades in Switzerland.
Transcultural psychiatry to respond to diverse needs. Transcultural psychiatry, or “cross-cultural” psychiatry, is a sub-branch of psychiatry that explicitly aims to respond to the diverse cultural backgrounds that international migrants have, as well as their life experiences - which can sometimes range from abuse, to torture and war-time experiences.
“Transcultural psychiatry is a subspeciality of psychiatry that acknowledges the cultural background of patients, and adapts to work within the patient’s framework of health and disease, rather than imposing a Western view of psychiatry on the patient,” explains Dr. Felicia Dutray, who is at the helm of transcultural psychiatry services at Appartenances, which is partially funded by the Canton of Vaud.
“If a patient believes that his mental health condition is due to ‘bad spirits’”, she says, referring to a framing common in traditional cultures, “ we don't judge him for it,” she adds. “Instead, we acknowledge that his framework is valid, and try to understand what it means for him so that we can work with it.”
For almost three decades, Appartenances has catered to the mental health needs of migrants in the French-speaking part of Switzerland, receiving nearly 800 patients a year. Like all psychotherapy in Switzerland, services are paid for by a migrants’ health insurance.
During most sessions, Dutray is assisted by professional interpreters to overcome potential language barriers, or to help the patient understand the aims of psychiatry and psychology, which are Western concepts that are sometimes unfamiliar to patients.
Cross-cultural psychiatry works. After two decades of working in the field, Dutray is convinced that transcultural psychiatry benefits patients.
“People feel relieved after sessions, and they keep coming in, sometimes for several years,” she notes. “In many cases, people’s symptoms reduce, and this is clear from our internal evaluations with patient questionnaires before and after sessions.”
One of the co-founders of Appartenances, Dr. Jean-Claude Métraux, prefers to avoid using the term “transcultural”. Instead, he refers to his work as “bridging between the worlds of patients and doctors”.
Although Métraux is no longer officially affiliated with the NGO, he still delivers training sessions on migrant mental health for the NGO. In 2019, some 1,400 people received some form of training, most of them social workers and health professionals, as well as interpreters.
‘Belonging’ goes beyond the consultation room. Apart from delivering training, Métraux also runs his own private clinic. Like Dutray, he is a strong believer that therapy should extend beyond the realms of the consultation room. Sometimes, this may involve getting in touch with lawyers and social workers to help patients with legal paperwork, or even finding a flat.
“The idea is to go further than the office, and to foster participatory collectives where people feel recognized in a nurturing environment,” says Métraux.
It is perhaps not a coincidence that Appartenances, which means “belonging” in French, also offers social spaces for children and adults, three of which are exclusive to women.
These collectives help migrants build their own networks, become autonomous, and integrate into society through a range of fun and useful activities, including art workshops, French classes, or even IT skills. In 2019, over 1,000 women from 66 countries engaged with social spaces at Appartenances.
Why fostering mutual recognition with patients is fundamental. Before any diagnosis can be made, doctors must first establish “mutual recognition” with patients and understand the social, political, cultural and juridical context that often shapes their health, says Métraux.
His comment is particularly pertinent given mounting evidence that migrants are often misdiagnosed, precisely because psychiatrists miss important contextual details during consultations. As a result, the quality of care they receive takes a big hit, studies show.
Discrimination, for instance, can trigger an auto-exclusion syndrome that is sometimes confused with psychosis in migrant populations, he observes.
But once patients are recognized as equals by their doctors, their psychiatric symptoms can be reduced in some cases, says Métraux.
“A lack of recognition is a deep-seated problem in society that exacerbates mental health issues of migrants,” he says. “This is why it’s so important to offer patients a context where they feel recognized, in the clinic and also outside the clinic.”
While his emphasis on mutual recognition may seem far-fetched to some, it is rather consistent with data on discrimination and mental health in Switzerland.
In fact, migrants that make it to Switzerland are more lonely, and three times as likely to experience discrimination, in comparison to locals without a migration background, says the Federal Office of Public Health.
“We know that mental health and discrimination correlate quite strongly in some migrant populations, but not all,” adds Efionayi.
The recipe to foster mutual recognition. Métraux emphasises that mutual recognition can only be established when difference is seen as an asset, rather than a deficit. He also warns against labelling migrants as vulnerable because it implies that others are invulnerable, thus fuelling the power asymmetries he is so motivated to break down.
In his sessions, he even goes as far as to share his own vulnerabilities to forge a bond with his patients. He also works hard to empower his patients to recognise their capacities, and their inherent ability to take control of their lives.
“To treat each other as equals, we need to show our vulnerability as doctors, and stop seeing difference as a deficit, as it is commonly done.”
Stockholm’s “mainstreaming” approach to migrant mental health. While Switzerland’s example has been studied around Europe, other countries with large immigrant populations have created their own distinct approaches to transcultural mental health services - leading to a useful cross-fertilisation of ideas and methods.
In Sweden,Stockholm’s Transcultural Centre has catered to the mental health needs of migrants, who make up some 20 per cent of the country’s population, for over two decades, says Dr. Sofie Bäärnhielm, psychiatrist and director of the centre since the early 2000s.
She says the Transcultural Centre fills the vacuum of expertise in migration and health, especially in medical schools, where there is “very little” training in cross-cultural mental health services.
A knowledge centre. Unlike Appartenances, Stockholm’s Transcultural Centre does not directly provide mental health services; rather it operates exclusively as a knowledge centre that offers support and training in the field of migration and mental health for asylum seekers, refugees or undocumented migrants.
For its training sessions, the Swedish centre uses a translated version of a cultural formulation questionnaire, which is routinely used around the world by healthcare and social workers to better understand a migrant’s context, including at Appartenances. The questionnaire, developed in North America, was incorporated into the fifth iteration of the Diagnostic Statistical Manual for Mental Disorders (DSM) several years ago.
In 2019, the Transcultural Centre trained over 4,200 people, including healthcare workers in outpatient clinics, nursing wards, as well as workplaces and NGOs, among others. Since the coronavirus struck, the centre has maintained its efforts, albeit through Zoom, with funding from Stockholm’s authorities.
When it comes to training, the Transcultural Centre’s approach is rather unique, as it extends beyond psychiatrists, health professionals or social workers - to train teachers, workplaces, churches, NGOs, or anyone else that is interested in migrant mental health, says Bäärnhielm.
“Our mission is to embed cross-cultural skills into Swedish society, as migrants don’t just interact with healthcare," she says. "They interact with the whole of society, and that’s why the whole of society must become more responsive to their diverse needs.”
Training non-specialists in responses to mental health crises is particularly important because it can take the edge off of overwhelmed mental health services, comments Dr. Inka Weissbecker, a WHO expert in mental health. Such whole-of-society approaches can make mental health support and care more widely available and accessible, while also addressing some of the root causes of poor mental health.
Silver bullets don’t exist. Although Amadou’s life has taken a new turn since he began cross-cultural therapy, it doesn’t work for everyone, and outcomes depend on a range of factors involving the migrant and his context - some of which may be beyond control. For instance, an unsuccessful asylum request can have devastating effects on mental health, irrespective of a therapist’s caliber or the length of therapy completed, Dutray warns.
It’s also difficult to independently evaluate transcultural psychiatry services; not only are studies expensive and logistically complex to conduct - especially for NGOs like Appartenances, but patients can be difficult to recruit, notes Dutray.
“If you don’t know where you’re sleeping or don’t have papers, you’re unlikely to take part in a study.”
On the upside, one robust evaluation of a cultural consultation service in 100 patients revealed that it can respond to the needs of diverse populations, improve diagnosis and treatment outcomes. The evaluation was published in the Canadian Journal of Psychiatry, and is one of many that have been produced in the past seventy years since transcultural psychiatry was developed, mostly in the peer-reviewed Transcultural Psychiatry journal.
Although today, transcultural psychiatrists have access to robust questionnaires like the cultural formulation questionnaire, the original English version must be translated and adapted to different contexts, which requires considerable expertise that is not always available, warns Bäärnhielm. She recounts how difficult it was to translate certain concepts when the questionnaire was first introduced, such as “race” - a controversial term in Sweden - and to ensure that the translated questionnaire was useful for its users.
“Not exactly lucrative”. Funding is another issue. Delivering specialized mental health services for migrants is “not exactly lucrative”, so there is little incentive to pay for high-quality training or research, said a Swiss expert familiar with the topic, who asked to remain anonymous.
“Transcultural psychiatry is a totally different ball game as compared to having a profitable private clinic for patients that can afford to pay,” said the expert. “As a result, transcultural psychiatry curricula are limited, there is a lack of high-quality training, and systematic evaluations of effectiveness are also scarce, as nobody will pay for it.”
Even in Sweden, renowned for its strong social welfare net, culturally responsive mental health services are also the exception rather than the rule because there is simply not enough interest, says Bäärnhielm. More awareness-raising and advocacy around needs and gaps associated with migrant health overall would help, she observes, as the field remains fragmented and resource-poor.
This article was developed as part of Changing the Narrative series of articles written by student or early career journalists, sponsored by The Local.
-This article was updated to reflect that cross-cultural mental health services cater to international migrants, rather than internal migrants.