05/07/2022

NPCE Event 2022: Psychotherapeutic care for refugees in the EU

Psychotherapeutic care for refugees in the EU was the topic of this year's symposium of the Network for Psychotherapeutic Care in Europe (NPCE). Under the chairmanship of Dr. Nikolaus Melcop, Vice-President of the BPtK, international experts discussed which challenges exist in the care of mentally ill refugees and how treatment can be ensured. Dr. Nikolaus Melcop explained that in the current situation it should not be forgotten that there are both Ukrainians and many other refugees seeking protection in Europe. There should be no distinction between refugees. Access to psychological and psychotherapeutic treatment must be guaranteed for all, regardless of their origin.

Specific needs of Ukrainians

Dr. Viktoriia Gorbunova, clinical psychologist at Ukrainian Catholic University, and Dr. Vitalii Klymchuk, mental health expert at the Ukrainian Ministry of Health, outlined the specific factors that should be considered in the care of Ukrainians. People experience various traumas; it is important to identify and treat them in time. In addition to psychological and psychotherapeutic help, social work and legal support are also necessary. Many Ukrainian refugees have relatives who have remained in Ukraine or must fight in the army, about whom they are worried. People are also concerned about whether to leave the country or when to return. Maintaining contact with relatives is therefore crucial and can be supported by free telephone calls. For some Ukrainians, even the Russian language might be retraumatizing. Therefore, Ukrainian-language counselling and care services should be available. Opinions about Russia as well as values and political attitudes towards war, knowledge about how to deal with aggression, hate and other emotions that are normal in times of war should also be taken into account by professionals. When involving Ukrainian specialists, it should be ensured that they have the necessary qualifications to ensure the quality of treatment. Video treatment is important to maintain care. Especially for soldiers, this is a suitable low-threshold form of treatment.

Group-based stress management for refugees

Claudette Foley, community psychologist, presented findings on the use of the group-based stress management course for adults "Self Help Plus (SH+)" developed by the World Health Organization (WHO). SH+ focuses on stress management for people who have experienced humanitarian crises. It is transdiagnostic, low-intensity and thus almost always safe for most the majority of people at most times, can be used in low-resource settings, and can be performed by trained laypersons. In addition, it takes into account cultural specifics. Studies have demonstrated that SH+ participants showed a lower risk of developing a mental disorder. SH+ is characterized in particular by its low-threshold nature, its cultural resonance, and the fact that it can be offered to many people. SH+ facilitators do not need to be professionals; they are primarily trained to assist, read out discussion questions and ensure interactive group work, provide guidance, and give culturally relevant explanations. SH+ facilitators do not provide counselling or therapy.

Train professionals to care for refugees

To provide good care for refugees, professionals need to be trained, says Iga Jaraczewska, a lecturer at Akademia Motywacji i Edukacji (AMiE). Not all psychologists and psychotherapists are experienced in treating traumatized refugees. These colleagues should be educated about which therapeutic measures are effective and which are ineffective. Also, it must be questioned to what extent standard treatment is sufficient to meet the care needs of refugees who have experienced war and terror. Guidelines and research on refugee care need to be promoted. AMiE has provided training for professionals and volunteers working with refugees to strengthen the specific skills required. The focus was primarily on practice rather than theory. Care for refugees also need to include how to dress, how to overcome language barriers, what customs and behaviours need to be acknowledged, and whether beliefs or religion needed to be considered, as well as gender issues.

Care requires cultural and language mediation

Teresa Sousa, a clinical psychologist at the Portuguese Refugee Council, provides psychological care for refugees. Before she can work with refugees, it must first be clarified which language is spoken and whether the patient is comfortable with an interpreter. Gender-specific aspects must also be considered; for example, only a female interpreter should be consulted. If a patient refuses an interpreter, it is important to find out the reasons, understand them and build trust. In the cooperation with language and cultural mediators, training and supervision are needed to avoid mistakes in interpreting in the therapeutic setting on the one hand, and to prevent psychological stress for the interpreters on the other. For the care, the value system of the patient must be understood, but also concepts of culture and society must be questioned. Psychotherapy is not well known in all countries; therefore, refugees must be better informed about the benefits and trust-building measures must be brought into focus.

NPCE calls for joint EU action

Mental health is a basic human right and essential for the well-being as well as the integration of refugees into society. Therefore, the EU must work with the member states to ensure that all refugees receive the care they need, regardless of their origin or residency status. This includes prevention, psychological primary care, and psychotherapeutic treatment, as well as language mediation and digital solutions. Common standards for mental health services should be developed and implemented in the EU, exchange of best practice and guideline development should be promoted. It must be ensured that quality standards are met, and care is provided by qualified professionals. Also, interdisciplinary approaches that can address the diverse needs of refugees should be promoted. To monitor the provision of care for refugees in the EU, member states should be required to report publicly about their activities at the EU level. Sufficient financial resources are needed to manage crises, but also joint mental health crisis plans are required. These should be developed together with clinical psychologists and psychotherapists.

Country reports

Germany

In Germany, refugees are generally not legally entitled to psychotherapy during the first 18 months of their stay. As a result, many of them do not receive treatment and their illness worsens. The Asylum Seekers' Benefits Act (Asylbewerberleistungsgesetz) must be further developed so that mentally ill refugees have a right to psychotherapeutic care, regardless of how long they have been in Germany. Refugees from Ukraine who receive temporary protection have been covered by statutory health insurance since 1 June 2022 and are thus entitled to psychotherapy. However, the language and cultural mediation that would be necessary for diagnosis and psychotherapeutic treatment is not yet paid for by the health insurance companies. It is urgently needed that the costs for interpreters in psychotherapeutic treatment must be covered by the statutory health insurance funds. Model projects for language and cultural mediation are only a temporary solution because they have limited financial resources and can only cover part of the care. The federal government should strengthen corresponding initiatives financially in the short term until language mediation is anchored in the social security and healthcare system.

The treatment capacities for mentally ill refugees are limited. For this reason, psychotherapists who are not licensed by the statutory health insurance funds must be authorized to provide treatment to refugees in order to increase the number of treatment options or to enable mother-tongue care. In addition, the health insurance companies must abandon their restrictive practice of approving applications for reimbursement in private practices. Only in this way can traumatized and mentally ill refugees be helped quickly. In addition, financial support must also be provided to the psychosocial centres for refugees and victims of torture, which are often the first point of contact for mentally vulnerable and ill refugees.

Since the asylum law reform of the last federal government in 2016, post-traumatic stress disorder (PTSD) is no longer generally considered a serious illness that can prevent deportations. The assumption that PTSD does not pose a significant and concrete threat to life and limb is technically incorrect. It is precisely the removal to a country in which the refugee felt or even still feels his or her life is threatened that can trigger suicide. It must be made clear that PTSD can in principle also constitute a removal ban. With the "Ordered Return Act" (“Geordnete-Rückkehr”-Gesetz) of 2019, it was determined that in the future only opinions of physicians will be considered when assessing whether a refugee may not be deported due to a serious mental illness. Since then, opinions of psychotherapists are no longer recognized in asylum procedures. Psychotherapists are licensed to assess mental illnesses. Any professional expertise provided by a recognized medical profession should therefore be considered in asylum proceedings.

Greece

Greece has been one of the main countries in the Mediterranean which have received an unprecedented number of refugees, asylum seekers, and displaced people, currently hosting more than 50.000 refugees. While many refugees exhibit impressive resilient and psychological flexibility despite having experienced multiple personal adversities or traumatic related conditions, their capacities to cope with daily challenges can reach a limit, beyond it, their mental health can be put at threat.

Mental health problems of refugees (data)

There are no official statistics about the mental health of refugees, but reports from supporting organizations, present a concerning increase in mental health problems of refugees. For example, according to the International Rescue Committee (IRC, 2020) and its work in collecting data (n=904) over the last three years in the three main refugees’ holding centers (camps) in the islands of Lesvos, Samos, and Chios, “as many as three out of four of the people, the IRC has assisted through its mental health program on the three islands reported experiencing symptoms such as sleeping problems, depression, and anxiety” whereas depression, post-traumatic symptoms, and self-harm have been reported among people across ages and backgrounds (IRC, 2020). These numbers are even increasing and alarming, following the pandemic, where a 66% rise was noted in the number of asylum seekers, reporting symptoms of post-traumatic stress disorder (PTSD), self-harm, and depression (IRC, 2020). The authors report potential reasons for these mental health problems, laying, partly because of several contextual parameters, including bad hygiene and other conditions in the camp, lack of main services, and involvement of refugees in complex bureaucratic procedures.

Albeit these concerning results, it should be noted that most of the emotional suffering is directly related to current stresses and worries, and uncertainty about the future (NHPSS, 2020). Most of the Mental health services in Greece for refugees, as shown below, follow the international key principles for promoting mental health and psychosocial well-being, viewing a refugee or a migrant as not exclusively more vulnerable to mental disorders on the ground of by itself being a refugee or an immigrant, but as individuals with an increased risk to stressrelated exposure conditions (e.g., abrupt and violent move from home, multiple losses, etc.).

Mental health support provision

The refugees and asylum seekers have the right to access public health services and psychiatric support through the national health system (ESY) which is made up of a mix of health service providers, broadly divided into primary, secondary, and tertiary tiers of service delivery (L 4378/2016). Despite the supporting legal framework, providing access to mental health services to refugees and asylum seekers, actual support provision to health care services is limited due to consistent barriers, including unstaffed services, availability of translators or cultural mediators, lack of services provision to cover the needs of a different group of the general population and persons without social insurance or vulnerable groups, and bureaucratic difficulties, such as delays of public health authorities to provide foreigner’s temporary insurance and health coverage number (PAAYPA).

Supporting organizations provide on-demand Mental Health and Psychological Support (MHPSS) services to refugees either as part of an on-campus clinic (e.g., in the largest campus clinic in the Kara Tepe area on the island of Lesvos) or in the local services in partnership with other actors active in the mental health field (e.g., in public community centers, hospitals or in collaboration with other actors supporting refugees, such as UNCHR, Caritas Hellas, ELiL, IsraAID, Iliaktida, PIKPA, IRC, KEP, IKA, EODY (former KEELPNO), RIC secretary, Asylum Service, EASO, PRAKSIS, MSF, ERCI, BRF, SMH, ARSIS and DRC).

Considering the difficulties refugees face to access public health psychosocial support services, the non-governmental organization (NGOs), such as the “babel” (https://babeldc.gr/en/homepage/ ) and the Doctors of the World / Médecins du Monde – Greece (MdM-Greece; https://globalcompactrefugees.org/article/quality-healthcare-andpsycho-social-support-refugees) have set up inclusive and free mental health and prevention supporting services to refugees.

There are variations in terms of the mental health services different providers support. For example, while in public mental health services the provision of service occurs mainly for those with a satisfactory level of fluency in the Greek language or provision given in the English language, other supporting organizations (e.g, Babel) accept anyone who has difficulty accessing or are being excluded from mental health services. Further, NGOs can provide support via different channels (e.g., via telephone, in person, or through other professionalusuals, such as the translator or the cultural mediator) and multidisciplinary professions (e.g., psychologists, social workers, etc.), whereas public health services limit their capacities mostly in in-person scheduled sessions (usually an appointment with a psychiatrist scheduled 2-4 months before the actual session, excluding the emergencies) and most often without the presence of the mediator or translator. Further, while public mental health services focus on symptom alleviation, medication prescription, and monitoring, other supporting organizations attempt also to empower resiliency, flexibility, and healing based on lessons learned, and to promote experienced processing, as well as the construction of new meaning and reorganization of individuals’ lives via copious influences, interactions, and social narratives.

NGOs and supporting organizations tend to respond more flexibly to mental health requests, often attempting to resolve the request with sensitivity and personalization. This reflects a more inclusive work framework where individuals’ requests are treated with compassion, respect, and understanding with professionals focusing on the needs with cultural sensitivity and competency. For example, referrals concerning drug and alcohol use are referred to specialized centers and so do referrals for severe trauma).

Psychological Intervention practices in Greece

As it is unanimously agreed that there is no single model or framework to provide mental health support to refugees and immigrants on the move to Europe, the main organizations supporting immigrants in Greece seem to adhere to internationally agreed evidence-based practices of mental health support provision. A scoping brief narrative review indicates the following with regards to the support services in Greece for refugees. Most of the organizations seem to:

Treat all people with dignity, support, and respect,
Provide some type of psychological first aid (PFA), using simple rules and techniques to respond to individuals’ distress,
Supply refugees and immigrants with updated factual information about where and how assistance can be obtained,
Provide relevant psychoeducation in languages that people can understand (e.g., the sexual and reproductive healthcare-SRH- and support for survivors of sexual and gender-based violence-SGBV services provided in Kara tepe camp in Lesvos by the MdM- UNHCR),
Prioritize some protection and psychosocial support for children particularly those who are separated, unaccompanied, and with special needs (e.g., Caritas day center for child refugees in Athens)
Some mental health services are now being provided remotely, including through multilingual telephone hotlines or over the internet through online sessions.

With regards to the psychosocial interventions, cognitive-behavioral interventions, in particular, narrative exposure therapy and other relevant interventions seem to be the most familiar therapeutic approaches employed by various professionals, although more training and thorough supervision are needed as most of the psychology staff working with this population is young and not well-trained with post-graduate degrees and specializations. There are services which make use of psychodynamic or humanistic-existential approaches or approaches based on the expertise the staff members exhibit. For those with severe and complex mental health conditions, mental health support is provided either remotely (online) or directly in safe ways, including monitoring of medication and continuation of treatment adherence.

Most of the refugees across the world (e.g., 84%), are hosted in developing regions and their access to quality mental health care is already very limited. After the pandemic where coronavirus causes great physical and mental affliction, the need to invest in continued health services, including mental health, and ensuring their accessibility to all is as evident and critical as ever.

References:

IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: Inter-Agency Standing Committee. 2007

World Health Organisation Regional Bureau for Europe. Policy brief on migration and health: mental health care for refugees. Copenhagen: WHO-EURO, 2015.

Turrini, G., Purgato, M., Ballette, F., Nosè, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International journal of mental health systems, 11(1), 1-14.

Papadopoulos, R. (2021). The approach of Synergic Therapeutic Complexity with Involuntarily Dislocated people. Systemic Thinking and Psychotherapy, 18.

Federica Micoli, F. M. (2022). Human Rights practitioners’ approach to refugees and migrants. A therapeutic psychosocial perspective (Doctoral dissertation, University of Essex).

Hungary

In the period following the outbreak of the Russian-Ukrainian conflict, a significant proportion of refugees arrived in Hungary. According to the data of the United Nations, approximately 570,000 Ukrainian refugees have arrived in the country since the start of the war. In comparison, 20,000 refugees have applied for asylum in Hungary, which is a low rate in Europe. This is not explained by the fact that 80 percent of the refugees in Hungary do not want to wait for the end of the war.

On the other hand, both the psychiatric care system and professionals working in private practice reacted quickly to the situation. Many Hungarian psychologists, psychiatrists and mental health professionals have joined the initiative to offer psychological assistance to Ukrainian people fleeing the war to Hungary. Multilingual access to counselling is available by phone, online or in person, and is free of charge. As written in the call published on pszi.hu, all this does not necessarily mean psychotherapy or psychiatric care, but counselling, helping and supporting conversation. The website provides access to a number of professionals, as well as the format and language in which they provide assistance. The Crisis Intervention Outpatient Clinic of Péterfy Hospital also aid the refugees: according to their call, psychologists and psychiatrists of the hospital provide pro bono crisis intervention (in Hungarian and English) and, if necessary, medical assistance as well. Finally, opioid substitution treatment centres have included opioid-addicted refugees in their methadone and buprenorphine programs.

Italy

In Europe there is an humanitarian emergency with millions of people forced by wars and misery, to escape and try to find safe havens by take long & risky trips that take long periods of time during which migrants suffer abuse and violence of all kinds. Many die in their attempt to reach safety.

In Italy, urgent healthcare is provided to everyone, even to undocumented people. If you are an asylum seeker, a refugee, or you hold subsidiary protection status, you are entitled to access health services on the same basis as Italians. You must register with the Italian public healthcare system (SSN). Once registered, you will receive a health card and you will have the right to: a family doctor or pediatrician, specialized medical visits, blood tests, vaccinations, hospitalization, and other different kind of health treatments, depending on your needs. Specialized health care, including mental health support, that you can book through the healthcare booking services.

The Italian system has a dedicated network of assistance services for mental health that you can access through your medical doctor. On the website of Ministry of Health you can also find the list of DSM (Department of Mental Health).

THE United Nations Refugees Agency UNHCR reports that at the end of 2021, there were 89.3 million people fleeing war, violence, persecution and human rights violations, an increase of 8 percent from the previous year and well over double the figure recorded 10 years ago, according to UNHCR's annual Global Trends report.

The Russian invasion of Ukraine and other emergencies have pushed the figure over the dramatic 100 million mark. As of 7 June 2022, there have been approximately 7.3 million border crossings from Ukraine and another 2.3 million crossings to return to the country. In Italy there are just over 80,000, the figure is current as of 25 May 2022 Ukrainian citizens who have applied for a residence permit for temporary protection, mostly women and children. In total, there are almost 39,000 Ukrainian minors who have requested temporary protection in Italy, just under half of the total. The data about Italy come from the Italian Civil Defense, which, confirming the good practice started with the beginning of the pandemic by Covid-19, has decided to publish in an open format data on the reception of those fleeing Kiev. Data that allow us to see how entries into our country experienced a peak in the first days after the invasion, and then decreased as the weeks went by.

The burden of trauma caused by the invasion of Ukraine is staggering before the pandemic of Covid-19. UNICEF calculated that each year 28 million of children are victims of trauma, and if not properly treated by expert mental health professionals their trauma will bring catastrophic consequences of their health on social health and the mental health of future generations. Now with the Covid-19 and the Ukrainian invasion, the burden of trauma is going to double up. Furthermore, if health professionals are not properly trained there is the risk of non-intentionally provoking iatrogenic damage and retraumatising the patients already victims of trauma. Nowadays we have safe, person-cantered approaches that are trauma-informed best practices.

Trauma informed best practices are crucial for the effective prevention and treatment of trauma.The scientifically formulated trauma-informed best practices exist for psychotherapists, medical doctors, pediatricians, psychiatrists, clinical psychologists, teachers, managers, nurses, volunteers, community officers, police officers, directors of services and juvenile delinquency personnel, judges and policy makers. In other words, each of those roles can do a lot to reduce harm and to refer people that for an ignorant professional may just look as unacceptable acting outs or lack of discipline that are to an educated eye symptoms that suggest referral to a well-trained trauma-informed mental health professional.

The Person Centered Approach Institute (IACP), where they train mental health professionals in trauma informed best practices and the Faculty of Psychology of the University of Turin (UNITO) will train totally for free of charge the first group of 15 Ukrainian psychotherapists wishing to become trainers in this field that is crucial for the health and wellbeing of the present and future generations.

Portugal

Preamble: The political context in Portugal is stable, and the Portuguese population have on long term a positive attitude regarding the refugee’s welcome, availability to provide voluntary help and giving support towards policies in order to promote their social integration.

The legal framework: The refugees are entitled for psychotherapeutic treatment in the same conditions as the national citizens. The main governmental Agency for Health Care, DGS, has published a directive covering the availability of the National Health Service access to all the refugees. The public health care services, following the DGS directive, promote equal access for the refugees and national citizens. The DGS manual for the psychosocial support for migrants, recommends the use of cultural mediators, for what it will be needed provided specialised training.

After the pandemic emergency, there was significant improvement of online psychotherapy, which could be useful with treatments for refugees dislocated from the city centres or health care facilities.

What is no longer available: A psychiatric service with an open consultation dedicated to migrant and refugees with a transcultural perspective.

What is still missing: The public health care service in Portugal is in a permanent deficit on material and human resources, mainly in the specialised field of mental health care. Specialised training of psychologists, psychotherapists and other health care professionals is needed, as well as decentralized clinical facilities with mediators and interpreters.

What is new in 2022: The previous required payment of moderation taxes for the services access was generally abolished. There is now a list of mediators and interpreters available to attend the requirements in clinical and social context.

We had in Portugal already a community of Ukrainians very well integrated. From the other side of Europe, more than 40.000 people arrived in a few months after the beginning of the conflict in Ukraine and were welcome. Arriving in Portugal, their problems are being perceived, in same accuracy as ours. The war in Ukraine and the wave of refugees gives to the problematic mental health a special relevance, and a new sensation of proximity. The traumatic experiences of the refugees give new relevance to mental health and the need of early intervention to prevent serious psychological disturbs. The political acknowledgement of this issue is required to make available psychotherapeutic care in Portugal to the general population.

The actual situation of war in Ukraine impacts not only the refugees arriving in Portugal, but also in the national and other residents in Portugal with different levels of psychological sufferance and fragility which demand measures for adequate scanning and psychotherapeutic support. Even if it was possible to give a first emergency psychological aid and psychotherapeutic care to refugees and migrants, it will be necessary to set up permanent structures providing specialised care, articulating the work of the ACM, the Higher Commissariat for Migrants, with the DGS, the main governmental agency responsible for Health Care Services.

It will be relevant if a national network with all interested on this subject, public and private and others already on the field could build a channel of communication centralising the resources available in an open platform and share their expertise. To face the emergency of war in Europe, with different gradations of contingencies with severe impact on mental health, we need not only contingency measures, but with urgence outline structural changes in the services of mental health care.

Best Practices: An informal network platform, PAR, has remained since 2017 operative giving support to refugees. The Chamber of Portuguese Psychologists has published a tutorial/manual of good practices for professionals which are working with refugees.

The Portuguese Centre for Refugees, CPR, has set up a psychological support specialised for refugees. A transcultural approach consultation and institutional supervision is now available provided by the CEC, a transdisciplinary group of academics and professionals.

Switzerland

Swiss Refugee Policy: The numbers of refugees in Switzerland are increasing every year. In May 2022, the number of officially recognised refugees was 74,047. But the numbers of refugees staying in Switzerland for a longer time is decreasing since 2016. The main reason seems to be that Switzerland is only used as transition country to other destinations. The Swiss asylum law follows the UN refugee convention of 1951. The first asylum law became effective 1981. Since then, it was revised several times with a tendency to make it stricter.

Psychotherapeutic Supplies for Refugees: The main goal is to provide easy access for refugees to these supplies. They are short time interventions that usually don’t last longer than 3 months, the intensity varies. They consist of psychoeducation and aim to stabilize the refugees and activate their resources. The interventions are provided by either psychotherapists, psychiatrists or trained peers or laypersons. They can either take place where the refugees live or online or in other places. Currently there are 10 officially recognized projects which have this approach.

STARK: a group programme to provide skills for the regulation of emotions, especially for single unaccompanied underaged males, lasting 14 weeks and taking place in the refugee facilities once a week for 90 minutes during school time, performed by a psychotherapist or psychiatrist.

Papilio: is an association that supports refugees to find a psychotherapist and help to refund an interpreter if needed, it’s for refugees of every age.
Consultation Psychothérapeutique pour Migrants (CPM): also, an association, but it offers psychotherapeutic or psychiatric support for refugees with psychiatric diagnoses especially for children and teenagers. It can be single psychotherapy, group therapy or family and/or couple therapy, it takes place outside the refugee facilities and can be reimbursed by the health insurances, usually consisting of 10 psychotherapy sessions.
PM as part of the project STRENGTHS: developed by WHO, laypersons are trained for 8 days to help refugees to cope better with stress and problems, to activate them and to strengthen their social support, until now only single therapy settings for children and teenagers outside the refugee facilities took place 6 times for 90 minutes, group therapy is also planned.
Digital psychological support for refugees is a guided App for self-help for adults, developed by the Swiss Red Cross and the University Berne, giving useful information about the Swiss health system and provides psychoeducation, exercises, and tips for the management of stress, problems, sleep, daily structure, chronic pain.
ComPaxion: is an easy access transcultural psychological consulting programme in the mother tongue of the refugees offered by a private association, it’s not a psychotherapy, but provides psycho-education and activation of resources, doesn’t deal with severe psychiatric diagnoses, but can help to discover them and to find a psychiatrist or psychotherapist to deal with it, with single or group setting with 5 to 10 sessions once a week or even more for 60 minutes outside the refugee facilities or online.
START (Stress-Traumasymptoms-Arousal-Regulation-Treatment): is an awareness-based programme with relaxing and stimulating exercises and psycho-educational trainings, offered in group setting for accompanied or unaccompanied children and teenagers with traumas caused by their migration experiences, taking place outside or inside the refugee facilities once a week for 150 minutes usually 10 times.
PsyAsyl: is an association that has organized a network of psychotherapist and psychiatrists who offer mostly free sessions for teenagers and adults, taking place in their practice with 15 hours at the most, frequency and intensity are not regulated.
Femmes-Tables and Men-Tables is an easy access programme offering moderated discussions about health, family and integration with peers often also with refugee experiences, taking place inside or outside the refugee facilities and lasting 2 hours with a varying frequency.
Brückenbauer*innen (bridge builder): are already integrated refugees helping traumatized refugees to deal with their everyday lives, supporting their self-efficacy and minimise their stress.

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