How a simple method helps traumatised refugees from Syria to cope with psychological distress. An on-site visit to the Psychologist Naser Morina at the Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine in Zurich.

«Would you like a new mask?» the receptionists asks friendly as we register at the reception desk of the Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine of the University Hospital Zurich. The department is still open during times of corona and offers consultation and therapies to people with psychological problems. At three o’clock, we have a meeting with Dr. Naser Morina, the Co-Head of the Outpatient Unit for Victims of Torture and War (AFK). The Psychologist and Psychotherapist is involved in the STRENGTHS* Project, which provides fast and efficient psychological support to mentally strained refugees from Syria and which is funded by the EU**. The project is carried out by a consortium of universities, psychiatric institutions and NGOs in Europe, the Middle East, Turkey, Australia as well as the UN Refugee Agency UNHCR. The Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine is one of 15 partner organisations of STRENGTHS and Naser Morina is its project leader for Switzerland.

The mental hardship of refugees and its consequences

«Refugees from areas of war and conflict suffer from double mental distress,» Naser Morina explains, as we sit down at opposite ends of the large table in the meeting room. «On the one hand, they are traumatised by their experiences of violence and the loss of family members, livelihood and home. On the other hand, the requirements of daily life in their host country represent an enormous burden for them. Everything is new and unfamiliar: the language, the culture, the behaviour of the people, the contact with the administrative authorities. We call it Post-Migration Living Difficulties. Many react by showing symptoms of stress, sadness, depression, concentration difficulties, isolation. They need professional help. However, this help cannot be offered sufficiently in the wealthy host countries in which traumatised refugees as psychiatric patients have to wait for up to 15 months until they receive therapy. Therapies involving interpreters are hardly available and specialised treatment services are overloaded.» The reduced therapeutic capacities are one side of the problem, the social and economic consequences are another. People suffering from mental disorders such as post-traumatic stress disorder, for example, find it hard to become integrated both in terms of language and jobs. The disease symptoms become chronic, the patients concerned depend upon social assistance and burden the health care and social systems of their host countries. This is why it is in the interest of both the refugees and the host society to timely recognise mentally strained refugees and offer them appropriate support.

Refugees from areas of
war and conflict suffer from double
mental distress.

During the refugee crisis in 2015, when more than one million refugees, mostly from Syria, immigrated via the Balkan Route, the political pressure in Europe to swiftly integrate these people was growing. The European Union provided funds to develop concepts and projects for the work with refugees. It was then when the Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine was contacted by the VU Amsterdam and was asked if it wanted to join the STRENGTHS Project. They explained that the project addressed coping strategies for psychological stress of Syrian refugees and was funded by the EU. Its objective was the adaptation of the WHO’s psychological intervention concept «Problem Management Plus» (PM+) to European countries and Syria’s neighbouring countries. The plan was to build a consortium of participating countries. Naser Morina was familiar with PM+ from his assignment in a refugee camp in the Jordan and immediately agreed to participate. He explains the reasons why.

Problem Management Plus (PM+)

«PM+ is a low-intensity, cost-effective psychological intervention based on evidence. It conveys strategies and techniques that quickly enable people to cope with mental stress themselves. This happens by means of consultations with so-called helpers during five sessions of ninety minutes each. The helpers are trustworthy lay-people, mostly refugees themselves, who were trained for their task but have no specific psychological or medical background. PM+ is ideal for the high percentage of refugees suffering from general psychological stress symptoms. However, it is not suitable for people with severe mental disorders. They still need professional treatment. But PM+ could help many mentally stressed refugees also in Switzerland to once again stand on solid ground and to be able to cope with everyday life.»

It is in the interest of both
the refugees and the host countries
to offer simple, low-level forms
of interventions to mentally
strained refugees.

The WHO originally developed PM+ for people living under precarious circumstances in poor countries, for example in slums or refugee camps, and who suffer from psychological stress but have no access to professional support. The concept was tested in refugee camps in Kenya, Pakistan and Nepal and worked very well. Subsequently, the WHO established a detailed manual describing the objectives and contents, the stepped-care approach as well as the role and behaviour of the helpers. For example, only one problem should be discussed per session and the helpers should not give advice but train their «clients» to come up with a solution by themselves. PM+ was received very well by the NGOs and was successfully implemented in refugee camps in the Middle East and in Asia.

PM+ for Europe

However, the WHO manual is not an instruction leaflet. PM+ has to be adapted to the corresponding cultural, societal and political context. This is exactly what the STRENGTHS Project now accomplishes for Europe. Naser Morina explains it as follows: «The deal is to test PM+ with Syrian refugees in highly developed industrial countries in order to assess whether the concept works here as well. Then, it has to be adopted to the country-specific circumstances and implemented accordingly. For this, we need the stakeholders from the healthcare sector as well, as they are the ones who shall one day implement PM+ into their range of therapy services.» The STRENGTHS Project follows a five-phase plan applying to all participating countries of the consortium. In the spring, Naser Morina completed phase three in Switzerland. It involved the evaluation of a pilot study with 60 participants with whom the feasibility and effectiveness of PM+ was tested. 30 of the participants received a PM+ intervention, 30 were part of the control group. Every participant was assessed about his or her psychological condition before and after the intervention. Naser Morina lists the criteria relevant for the assessment of the study results: «One part of the investigation is to find out whether psychological stress and depression as well as the difficulties in everyday life of the participants have decreased or not. Other parts are medical and economic indicators; whether someone uses the services of the healthcare system more or less after completing the PM+ intervention, whether the costs of the intervention are compensated by reduced medical expenses. And we also talk to the stakeholders, physicians, social workers, psychologists and administrative authorities and ask whether they have witnessed a change in the refugees after the intervention.» We ask, «What are the results of the pilot study?» – «The results are promising,» Naser Morina says. «Every participant of the intervention group showed less stress symptoms after five sessions, was able to deal better with everyday situations and had less difficulties coping with the system in Switzerland. In contrast, the situation for the participants of the control group did not change during this period of time.»

The central aim of these consultations
is to listen to the people
and to take their sorrows seriously.

Since August, the effectiveness of PM+ is being investigated again during phase four of the project in a large randomised study with 380 participants. Thereto, Syrians were recruited who conduct the PM+ intervention as helpers. The candidates had to meet a precise requirement profile. «They have to speak Arabic and sufficient German or English, they must have attended school during at least twelve years and have open-minded, empathetic personalities; they have to be able to distance themselves from the situation and must not develop a helper syndrome,» Naser Morina states. Based on these criteria, 13 helpers were chosen who received training during eight days according to the WHO guidelines; during their assignment, they are accompanied by supervisors who, at the same time, are in charge of the professional quality assurance.

The helpers’ experiences

By now, it is four o’clock and Naser Morina introduces us to the helpers Malik Ossi, Kaser Alasaad and Inaam Al Haristany who join us in the meeting room. They have just finished PM+ consultations with Syrian refugees. Malik Ossi tells us that he just met a man in his fifties for his third session. Malik Ossi himself fled to Switzerland five years ago from northern Syria and is now conducting social work studies at a university of applied sciences. The man he talked to feels pressured to learn German but does not know how. Inaam Al Haristany, who came to Switzerland from Damascus with her husband 19 years ago for professional reasons, talked to a young woman this afternoon. She has been here for 18 months and suffers from homesickness, misses her family and the disputes with her neighbours add to the burdens. This was the young Syrian’s first session and Inaam Al Haristany was able to show her how she can cope with the stress by herself. The helper Kaser Alasaad is originally from Damascus as well and came to Switzerland seven years ago as a refugee; today, he works as imam for Muslim communities, provides spiritual assistance in prisons und is a contact person for authorities. The old man he just talked to is in great distress because he cannot visit his ill daughter in Germany. He has not seen her in eight years as his resident status in Switzerland does not allow trips abroad. «I cannot solve this problem for him, but I can show him ways of dealing with the problem,» Kaser Alasaad says and adds: «The central aim of these PM+ consultations is to listen to the people and to take their sorrows seriously. Authorities and social workers do not have the time for this and when problems arise the general practitioner prescribes painkillers.» At the end of our short meeting, Inaam Al Haristany addresses an experience that is very important to her: «I am conducting these consultations with both men and women and I am respected as an equal, both as a woman and an Arab. In Syria, this would be impossible.» As Naser Morina walks us to the exit of the clinic afterwards, he confirms this statement. «We asked all beneficiaries whether they preferred a man or a woman as their helper. Almost all of them said that it did not matter. Gender, religion or ethnic affiliation are hardly an issue for the participants of this study.»

The corona pandemic delayed the works of the STRENGTHS Project as well. By now, however, the project has picked up speed again. When it ends on 30 June 2022, every participating country will have a comprehensive tool at its disposal for the implementation of PM+ in their work with Syrian refugees, including training material, tutorials on supervision and ensuring quality. This tool will be available for public healthcare institutions and can be adapted quickly and with little effort to other refugee groups as well. For Switzerland, Naser Morina has already started to adapt the PM+ manual for refugees from Eritrea, Sri Lanka and Turkey.

* STRENGTHS – Syrian REfuGees MeNTal HealTH Care SystemS

** The part of the STRENGTHS Project for Switzerland is funded by the State Secretariat for Education, Research and Innovation SERI.

Interview with Naser Morina (in German)