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Journal of Psychology & Psychotherapy

Hanewald et al., J Psychol Psychother 2017, 7:3 DOI: 10.4172/2161-0487.1000307

Open Access OMICS International


A Concept of Clinical Care for Refugees on a General Psychiatric Ward

Bernd Hanewald1*, Oliver Vogelbusch1, Astrid Heathcote2, Frank Stapf-Teichmann1, Buelent Yazgan, Michael Knipper3, Bernd Gallhofer1 and Markus Stingl1

1Justus Liebig Universitaet Giessen, Centre for Psychiatry and Psychotherapy, Giessen, Hesse, Germany 2Ahwatukee Psychological Services, Phoenix, Arizona
3Justus Liebig Universitaet Giessen, Institute of the History of Medicine, Giessen, Hesse, Germany


Refugees and asylums seekers can present as a highly vulnerable group with an increased risk for the development of mental disorders. We developed and established a concept of clinical psychiatric care for refugees on a general psychiatric ward that systematically takes into account the social, cultural and legal dimensions relevant for mental health of refugees. This concept presents a framework for treatment, which not only offers security and orientation for the patients but also for the treatment team. The present treatment guide should provide structured working in apparently hopeless situations, which due to language dif culties, trans-cultural features and serious diseases at least in the short term seem to be unchangeable. Due to the implementation of the treatment concept, from the perspective of the team, there is a noticeable relief and signi cant improvement concerning the interaction with refugees on the ward. We have experienced that handling patients according to this treatment concept has mutually in uenced both, the treatment outcome of refugees as well as the clinical setting. It became possible not only to integrate refugees on a common psychiatric ward but opens the way for reciprocal exchange between treatment team, refugees and other patients in terms of acculturation. We expect that in the future the number of asylum seekers will remain high because of wars across the globe. Therefore, it can be assumed that there will be a need for differentiated and exible treatment concepts for the inpatient treatment of refugees also in the future.


Keywords: Refugees; Post-traumatic stress disorder; Treatment; Psychiatric ward; Clinical care


Over the past decade, millions of individuals from war torn countries have ed their homes to nd asylum in Europe, Canada, and the United States. Over one million refugees entered Germany between 2015 and 2016, many of which have witnessed traumatic events, including deaths and destruction, leaving them with memories of terror, o en meeting diagnostic criteria for trauma and stress related disorders like post- traumatic stress disorder (PTSD, according to DSM V) and other serious mental health concerns (depression, anxiety, addiction, etc.). As a result, upon arrival to their new “homes”, refugees o en require psychiatric or psychotherapeutic care, which can be challenging because of unique spiritual, social, cultural and legal aspects of migration. In this article, we present a concept of clinical psychiatric care for refugees in a general psychiatric hospital that systematically takes into account the social, cultural and legal dimensions relevant for mental health of refugees. First, we provide an overview about the medical and psychiatric dimensions of refugees ́ health, followed by a chapter about the social, cultural and legal aspects. Later, the de nition of nine principles for comprehensive psychiatric care of refugees and asylum seekers, derived from the multi-agency guidance note on mental health and psychosocial support for refugees [1] will be presented. Finally, we will describe the practice concept for the treatment of refugees, it ́s implementation at the Giessen University Hospital as well as the resulting consequences for the treatment process and the therapeutic “setting”, respectively. is concept was developed in an ongoing institutional developmental process starting in 2011 in response to the growing number of refugees demanding psychiatric treatment.

Mental Health of Refugees

Refugees and asylums seekers can present as a highly vulnerable group with an increased risk for the development of mental disorders. In international surveys the prevalence of psychological trauma- related disorders in refugees are in the range of 30-70% [2-6]. In clinical samples of victims of torture as many as 80-90% may meet

J Psychol Psychother, an open access journal ISSN: 2161-0487

diagnostic criteria of PTSD [7]. In their study of asylum seekers living in Germany, Gäbel et al. found a prevalence of 40% of individuals meeting criteria for PTSD [3]. Traumatic experiences may not only contribute to the development of symptoms of PTSD, but can also cause a broad range of other serious mental health problems such as depression, anxiety disorders, addictive disorders, personality disorders as well as somatoform disorders [8]. Furthermore, there is a signi cant interaction between psychological traumatization and its e ect on the immune system, potentially triggering physical illness. Psychological traumatization is associated with a number of diseases, such as diabetes [9] or coronary artery calci cation [10]. Vice versa, physical illness can a ect the course of mental health [11]. However, the relation between psychological trauma and physical health is complex and more studies are needed to clarify the relationship more detailed. Nevertheless, 60- 100% of individuals who meet diagnostic criteria for PTSD also have additional medical or mental health disorders [12-14]. In general, the risk of developing PTSD results from a complex interaction of several risk factors (genetic predisposition, early adverse childhood experiences, lack of social support systems, lack of control, resilience to adverse events) and traumatic experiences and almost linearly increases with the frequency of repeated psychological traumatic experiences, up to nearly 100% when direct confrontation with fatal experience of violence continues [15,16]. is is especially important in the context of forced migration: Traumatic experiences mainly happen in the country of origin (e.g. war associated trauma, persecution), but also during the

migration process, which is o en associated with experience of extreme and o en fatal violence, hunger, loss of relatives and/or friends and even incarceration and torture. Even a er arriving in the country of destination several factors can maintain or even intensify symptoms of PTSD – in contrast to the expectations of refugees, expecting to nd security and opportunity for recovery.

Legal research con rms that residence status is essential for non- citizens to gain access to social systems in host societies [17]. Lack of security stemming from insecure residence status hinders refugees to access adequate health-care. Existential fears of being deported impede therapy. Standard therapeutic approaches that ignore the legal dimension not only fail to account for the real needs of refugees, but also abstain from using legal counseling as an essential resource for “syndemic care” of refugees [18]. From a medical point of view, the importance of the legal status and legal practice is evident when it comes to recovery; therapeutic e orts to reestablish the very basic human need to feel safe are hampered by the legal status and a ect a sense of inner stability, a necessary precursor for successful treatment outcome of PTSD. As we have shown before, the legal status, which o en remains unclear for a long time, and the complicated asylum procedure can undeniably be seen as factors that essentially maintain the disorder, compromise psychotherapy, and intensify past traumas [19]. In this respect, the diagnosis of posttraumatic stress disorder is actually not accurate because there is no “post”-traumatic situation [20].

is nding corresponds to trauma-theoretic approaches like the “sequential traumatization” [21], but also to empirical studies on the importance of safety, social support and compassion for victims of traumas in the host country, to assure for a positive psychological prognosis of traumatized refugees [22,23]. Moreover, multiple stressors well-known to negatively impact mental health o en cumulate in refugees and asylum seekers: Desolate housing situation, loneliness, helplessness, lack of meaningful activities, the loss of social structures, grief, loss of families and feelings of guilt. Examples speci cally related to the situation of refugees, are the loss of families resulting from migration-related lack of contact information or the real death of their relatives. O en the families of the refugees have nanced the escape from the war zone with large input of desperate nancial resources and resulting expectations that the escaped refugees have to support those le behind nancially or have to initiate a family reunion in the future. According to this, feelings of guilt might arise towards family-members (e.g. children, husband/wife) who have to remain in ongoing dangerous living situations while the escaped refugees are not able to perform these obligations. Beside this resulting pressure, the subjective fear of deportation, o en due to the lack of understanding the legal proceedings in asylum trials, can enhance helplessness, uncertainty and confusion. All in all, these factors imply ongoing high stress for the individuals and impede psychological healing or recovery, but even worsen existing mental health problems and accelerate the development of new ones.

Challenges for Psychiatric Care

For clinicians the aggravating impact of social, political, legal and economical factors on mental health issues of refugees and their deleterious interaction with therapies and treatment outcome is a daily experience.

When o ering psychiatric care for refugees, both formal and substantive di culties will have to be overcome. In Germany, due to a lack of therapists, even patients with health insurance coverage have to wait six months on average to get outpatient psychotherapeutic care [24]. Refugees who are in the asylum seeking procedure usually receive psychiatric-psychotherapeutic care only under the Asylum Seekers

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Bene ts Act, which covers only the bare minimum of healthcare. Secondly, clinicians o en have limited knowledge of trauma therapy, with the additional obstacle of language barriers, which compromise successful treatment and recovery from mental health concerns. In most cases, practitioners have very little experience with psychotherapeutic treatment settings that include interpreters; even if an interpreter assignment is being considered, the nancing of the interpreter is another issue, which has to be clari ed [25].

Although refugees o en su er from psychological or psychiatric disorders, other symptoms lead to acute hospital admission in most cases. Predominantly, refugees o en report somatic complaints and pain such as headache, chest pain, stomach pain or sleep disturbances instead of describing psychological symptoms [26] and it is currently not ensured that accompanying or underlying psychiatric disorders can be detected in an adequate way. In addition, many refugees with mental health problems are also o en afraid of being stigmatized when they make use of psychiatric-psychotherapeutic treatment [27].

From our clinician perspective a er more than ten years of caring for large numbers of refugees, we address some obstacles in developing su cient treatment plans for refugees in psychiatric hospital settings, especially if the continuity of symptoms results from chronic, ongoing psycho-social stressors, legal di culties (pertaining to immigration status) and the individual’s di culty with introspection and describing their emotional status.

Patients o en expect an active part of the doctor or the psychotherapist; they also expect clear advice or procedures and frequently perceive the therapist as “incompetent” because he or she is engaging the patient in the development of a treatment plan, frequently adding to gaps in communication.

Beyond that, from the health professionals and the patients’ point of view, cultural and religious issues are perceived as challenging in treatment and care. In the course of intercultural encounters, for example between medical sta and refugees, the importance of cultural orientations related to the country of origin has to be viewed with caution for the problem of stereotyping instead of approaching the identity, values and needs of the individual [28]. Refugees have le their familiar surroundings and the meaning of cultural identities, values and orientations can be seriously a ected and modi ed during the migration process. Moreover, many refugees do not have a lot of social inclusion or reliable social contact to people in the host country and live in a very particular social situation de ned by legal status, elements of cultural diaspora and a marginalized social position. A further important aspect to be considered consists in the “culture” on the side of health professionals and medical sta , both regarding the “professional culture” with its speci c understanding of and approach to (mental) health and illness [29], as well as the individual’s identity and personal culture and possible presuppositions and even prejudice about members of foreign origin or ethnicity.

According to our experience, in clinical practice the most important challenge for culturally sensitive care is not to focus on the (assumed) culture of the “other”, but to emphatically approach “what matters most” to the patient [28]. In the particular case of migrants, a super cial use of “culture” entails the danger of preventing to see relevant aspects of the migration process and of the current living conditions [30]. In case of asylum seekers, for example, daily life and social relations are shaped to a large extent by the particular situation of housing in a shared accommodation with all activities and prospects being strongly conditioned by the strict demands of the complex asylum procedure.

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Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307


Obviously, the resident status is a very concrete and decisive factor that de nes the lives of refugees and asylum seekers in Germany and is thus of upmost relevance for the therapeutic relationship and process. Previous trauma and negative treatment experience in the home country can result in fear and distrust towards the treatment team, only jeopardizing successful treatment of PTSD, and are assumed as “doubling of paranoid attitude towards the situation” by Henningsen [31]. On the other side, the treatment team may feel helpless without power and lack of established treatment concepts for brief, psychiatric inpatient treatment for refugees [19].

Because of the aforementioned reasons traumatized refugees are only rarely treated in an adequate clinical way, in consequence, e.g. PTSD or severe forms of psychosis may become chronic and may lead to recurring acute psychological decompensating, possibly endangering themselves and others and requiring emergency mental health interventions in an in-patient setting. Acute treatments o en remain super cial and from a clinical or nancial point of view ine ective.

Within the last six years, the present treatment concept has been designed and developed practice-adapted based on the long-standing experiences in the treatment of traumatized refugees, in order to cope with the di culties mentioned above, to improve the quality of treatment and to ameliorate both, the patient’s and the therapist’s satisfaction with the treatment.

Based on theoretical considerations, clinical experiences and inspired by the “Multi-Agency Guidance Note” of the Mental Health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the Move in Europe [1] we identi ed the following nine major principles to guide psychiatric care for refugees in clinical settings which are described in clinical practice in the next chapter. It will be noted that these principles are essentially based on general principles of human rights and medical ethics that of course apply for all patients, but are of particular relevance for the treatment of traumatized refugees in clinical settings.

  1. Treat patients with dignity and respect, support self-reliance

  2. Respond to refugees in distress in a humane and supportive way

  3. Provide information about services, supports and legal rights and obligations

  4. Provide relevant psycho-education and use appropriate language (with a translator)

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6. Make interventions culturally relevant and ensure adequate interpretation

7. Be prepared/help to provide ongoing psychotherapeutic treatment a er discharge from hospital – if necessary

8. Monitoring and managing wellbeing of sta
9. Do not work in isolation: Coordinate and cooperate with others

A Hospital ́s Concept for Psychotherapeutic Treatment and Care

In our clinic we have implemented a treatment concept for refugees ́ care answering the mentioned features with integrative approaches. Our objective is to o er specialized psychiatric and psychotherapeutic treatment with explicit consideration of the particular needs of refugees and asylum seekers and support for the treatment team in challenging situations.

Starter package for refugees

Immediately a er admission to the hospital, the treatment-related admission interview is implemented by the physician responsible, supported by the primary nurse and, if required, an interpreter. Refugees get detailed information about the treatment concept, for spatial and contextual orientation. e primary nurse providing information about the ward process, the ward order, the contents of the o ered therapies, the German Skills Training and the social services, answers outstanding issues, questions and wishes of the patients. In addition, a guided tour around the ward and the clinic is o ered. is information and orientation procedure is repeated a er one week. In this context, any open questions can be clari ed, and the patient is invited to give a feedback regarding his rst week of treatment.

To introduce the multimodal treatment concept to the refugee patients, the procedures and contents of the di erent treatment o ers are explained. In an introducing session with an occupational therapist the concept and goals of the occupational therapy and exercise therapy are presented and the new patients are assigned to the individual ward groups, consistent therapeutic visits take place. Besides the initial diagnostic assessment, the therapeutic need is basically re ected and the patients are assigned to their individually responsible therapists. e individual single session treatment is based on the guidelines as mentioned below.

Right from the start, all patients ́ contacts are interpreter-aided in case of need (Figure 1).

5. Strengthen family support


Figure 1: Admission and starter package


J Psychol Psychother, an open access journal ISSN: 2161-0487

Volume 7 • Issue 3 • 1000307

Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307


erapeutic sessions

During the individual psychotherapeutic treatment of refugees, the therapeutic alliance and the patients ́ feeling that the therapist is on their side, is of crucial importance. Especially for traumatized refugees, psychotherapeutic “security” is essential so that despite of external unpredictability, a sense of stability and optimism can be established and a “safe space” for the subjective experiences before and during the ight can arise. In this context, also contradictions within the therapeutic “story telling” about the escape from terror and the personal history are possible without fear of negative consequences and can have a positive impact on treatment success - in contrast to concerns regarding their credibility, as it is unfortunately o en the case at interviews in the asylum procedure.

Distrust and unrealistic expectations towards the treatment need to be taken into account. erefore, the patient’s expectations towards a German psychiatric hospital, which also covers previous experiences with or knowledge about psychiatric hospitals in the respective country of origin have to be discussed in all the details. It is also important to clarify if the patient can orientate himself in the clinic, if he is surprised by anything, if anything meets his expectations, and the clari cation of unresolved questions. Subsequently, basic knowledge of functioning in German psychiatric hospitals or goals of psychotherapeutic treatment should be conveyed. In doing so, not only information about somatic, psychiatric and psychosomatic disease models is to be conveyed, but also the responsibilities of the individual professional groups in the psychiatric hospital have to be explained. At the end of one therapeutic session, stabilization techniques like attentiveness, body awareness techniques, and the Butter y-technique are to be introduced gradually. e patient needs reassurance that he or she is safe now and past experiences are not part of their daily lives and cannot hurt them anymore. For stabilization legal consult is added and provided by the lawyer of the person concerned and/or the Refugee Law Clinic, to get advice for the asylum processing.

Furthermore, the patient is asked to describe the main psychiatric and physical symptoms, which may lead to a more intensive diagnostic process and speci cation of concrete and realistic treatment goals. erefore it should be clari ed, which role in the therapeutic process the patient plays in his point of view: For example, a passive patient may expect an active leading role of the therapist, while a cautious, restrained and inquiring therapist might be considered as incompetent. However, we try to establish a partnership of patient and therapist in terms of shared decision-making and empowerment of the patient. at is why the roles of both, the patient and the therapist must be explained and re ected in order to avoid misconceptions and disappointments.

Parallel to that, further stabilization techniques like ‘Position of Power’ [32], ‘Safe Place Imagery’ [33,34], ‘Absorption Technique’ [35], dealing with emergencies, dissociation breakpoints and CIPOS [36] can be introduced. e described symptoms are sorted, possibly summarized to clusters, a trauma map is created, among other instruments the Impact of event scale [37] and the Dissociative experience scale [38] are used for further diagnostics. e primal anamnesis is supplemented by the information and data gathered and if necessary, a written medical opinion about the type and extent of the disease, type of the necessary treatment as well as the prognosis according to the principles of scienti cally sound expert opinion on further legal instigation is created.

Psycho-education dealing with PTSD in general and the individual symptoms in particular follows; also there are other imagination

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exercises introduced and possibly progressive muscle relaxation can be conveyed. Exercises, which have already been introduced, are repeated and the patients are reminded that it is necessary to practice regularly and independently; if necessary, imagination exercises get translated by interpreters and digitized as sound le (mp3, smart phone) in the mother tongue.

If necessary, further tools for stabilization and safety can be conveyed. In case of su cient stabilization, techniques for working through trauma can be carefully introduced.

A er clarifying the further approach, still existing individual issues and symptoms of the patient are handled separately, if necessary by taking into account the further family members.

Generally, it is advisable in communicating information to allow the patient taking notes, but at least to have him sum up what has been said in his own words.

In order to improve the integration into the everyday life of the ward, recreational activities include board games, table tennis, cooking together and Nordic walking. It might be helpful to assist the individual in attending group therapies at the beginning of treatment.

e preparation of the discharge includes the planning of the follow-up outpatient treatment, contacting for example the trauma outpatient department or resident therapists (Figure 2).

Language and interpreting

If there are any language barriers, interpreters are deployed as language and cultural mediators in medical, nursing and therapeutic conversations. e 24 h on-call service of the commissioned interpreting agency is also in acute cases a prompt support, for example for the emergency ward when there are urgent admissions. e language and cultural mediators get involved into the treatment context in preliminary and follow-up talks and provide valuable support for scenic and “cultural” understanding.

e inclusion of interpreters includes the information of the interpreter about the expectations of the hospital towards con dentiality and privacy of the patient. is includes that the interpreter and the patient get to know each other before the individual therapeutic consultation and clarify in which language they can talk to each other. During the consultation, the interpreter is supposed to translate as literally and completely as possible, without own interpretations, even


P = physician

T = therapist

N = nurse

R = resident

E = ergotherapy

Ph = physical therapy



Figure 2: Weekly treatment programme


Volume 7 • Issue 3 • 1000307

Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307

if the patient’s statements seem illogical, unpleasant or inappropriate. Translations are to be performed in rst person view, including the translation of own inquiries, as well as the translation of emotional expressions and colorings. In that regard, the interpreter is obliged to ask questions if, for example, medical details are not understood correctly. e interpreter is requested to give a feedback a er the interview to clarify if he had the impression that the patient was able to understand everything and follow the conversation, and also if there were any critical points and characteristics during the interview from his point of view. Care should be taken that there is a stable interpreter contact. e hospital covers all expenses for interpreters.

Furthermore, the patients can improve their linguistic competence and skills of daily life, e.g. dealing with authorities, in the daily “German Skills Training”, o ered by a linguist. e patients are introduced to the German language and culture; skills are conveyed in the form of role- plays, e.g. simulation of a telephone conversation.


Within the framework of monthly carried out trans-cultural supervision, all the “cultural“ meanings, ideas, and value judgments, which are relevant for the treatment context, can be re ected within the team. In contrast to the concept of culture, which understands culture as a parameter that is static and “can be learned”, the underlying idea is that the patient’s own and incomparable biography in the ethnographic interview and the behavioral dynamics becomes palpable and comprehensible in the here and now. Besides trans-cultural supervision, there is also behavior therapeutic supervision, as well as, depth psychologically oriented supervision every two weeks.

Legal questions

e lack of a residence permit, for example in case of suspension of deportation or threatening return ight, is essentially an etiological factor for mental disturbances of refugees and impedes therapy. rough close cooperation with lawyers of the Refugee Law Clinic (RLC) in Giessen and legal advice centers, the legally complex issues can be integrated into the treatment. e RLC is an interdisciplinary and practice-oriented training site at the Department of Law of the Justus Liebig University Giessen. e students are enabled to advise asylum seekers under supervision for legal counsel. Clinicians of the Hospital for Psychiatry and Psychotherapy give lectures on mental traumatic disorders at the RLC and o er an additional supervision to the students of the RLC. At the same time, the RLC o ers legal advice to patients with questions concerning asylum law at the Hospital for Psychiatry and Psychotherapy.

During the treatment process, in collaboration with lawyers, the current status of the asylum procedure is clari ed. In case of need, a medical statement describing the actual medical and psychiatric condition of the patient will be written down, for subsequent legal purposes. e inclusion of legal aspects in the treatment process o ers the possibility to achieve relative stability of the current living condition and might create the prerequisites for further trauma- focused interventions.

Even though legal advice can be delivered in the hospital setting, unrealistic expectations of the refugees towards the hospital might arise, associated with the hope that the hospital can have a decisive in uence on the asylum procedure or can even take legally binding decisions independent from the responsible authority. To avoid misunderstandings, the explanation of the di erences between the roles of the treatment team, lawyers and responsible authorities in the

J Psychol Psychother, an open access journal ISSN: 2161-0487

asylum procedure is of decisive importance.

Internal continuing education

e trauma-therapeutic skills mentioned above are trained and deepened in a modularized curriculum for inter-professional mediation of trauma-therapeutic basic competence that has been developed and approved in the hospital. e curriculum consists of 7 two-hour modules and comprises theory, self-awareness and practical training (in e.g. mindfulness, imaginations such as “inner safe place”, techniques from EMDR such as butter y technique, absorption technique or position of power) in small-group work. Training also includes the preparation of a trauma-associated anamnesis-report and a trauma map; the Impact of Event Scale (IES) and the Dissociative Experience Scale (DES) are introduced. e participants get personal experience in mindfulness, are introduced to working with the “inner child” and dealing with emergencies, dissociation breakpoints and CIPOS technique (Constant Installation of Present Orientation and Safety).


In order to improve the outpatient treatment opportunities in the eld of trauma, the Trauma erapy Center Giessen at the Department of Psychiatry and Psychotherapy at the University Hospital Giessen opened in 2015.

e clinic also functions as part and home of the Trauma-Network for victim support and victim emergency aid in Hesse. e Trauma Network was founded in 2012 under the leadership of the Department of Psychiatry and Psychotherapy in Giessen and connects the regional supply structures, enables a cross-professional exchange and o ers the opportunity of continuing education. e Trauma Network Middle Hesse includes physicians and psychologists from various psychiatric and psychosomatic hospitals, pastors, resident doctors and psychological psychotherapists, interpreters, volunteers, employees of the Refugee Law Clinic Giessen, employees of welfare associations and employees of psychosocial centers.

To improve the o en still de cient interface between in-patient and out-patient treatment there are contacts to networking with the outpatient department of the Department for Psychotherapy and Psychoanalysis Giessen as well as the behavioral-therapeutic health care center at the Department of Psychology at the Justus Liebig University Giessen.

An interdisciplinary contact to the Department of Law consists in two respects: scienti cally the seekers are attached as members of the research group migration and human rights (FGMM) and there has been a co-operation with the Refugee Law Clinic (RLC) since several years.

Summary and Conclusion for Clinical Practice

Considering the high case numbers - in 2015 the Federal O ce for Migration and Refugees in Germany accepted 467.649 asylum applications - 441.899 of them were rst applications and 34.750 subsequent applications [39], it is expected that in the future the number of asylum seekers will remain high, because of wars across the globe - it can be assumed that there will be a need for di erentiated and exible treatment concepts for the inpatient treatment of refugees also in the future.

is concept for the treatment of refugees in an inpatient psychiatric setting represents an attempt to integrate refugees in a mental health unit along with other patients who do not share the same stories. Even

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Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307


though the experience of eeing a warzone is very unique and may require a speci c type of psychological treatment, integration with other patients is very important. We believe that this concept is necessary because it presents a framework for treatment, which not only o ers security and orientation for the patients but also for the treatment team and thus allows exibility to ful ll the respective individual needs of all of the patients. Inpatient psychiatric treatment of refugees o en starts in acute, escalated crises, which has multiple triggers including previous trauma history, current con icts, experiences of loss, prior illness and legal issues, in some cases with the threat of deportation. ey o en present with severe anxiety, depressive symptoms and signs of PTSD, addictive behavior, physical complaints and suicidal tendencies. Despite of o en existing references for an indication of the presence of PTSD, trauma therapy in the classical sense with acutely decompensated refugees is not possible because of the severity of symptoms. It is really important initially, to o er a safe place where the person in crisis can calm down within a psychiatric hospital, and being taken seriously when it comes to their anxieties and concerns. It is also important to address the individual with an appreciative, validating and respectful approach, while providing reassurance that they are not “in trouble”. Our observation shows that such a supportive setting o en leads to de-escalation of the patient and enables further stabilizing therapeutic work, even though external circumstances cannot be changed (e.g. housing situation).

Apart from the therapeutic approach, our concept also includes a mediating function in both directions. On the one hand, it assists in the process of providing support in understanding German immigration policies during the asylum procedure and also to inform them about support services, such as social counseling or legal advice. On the other hand, preparing meaningful psychiatric expert statements for asylum seekers may help authorities to develop a better understanding in recognizing and critically acknowledging mental illness, especially PTSD, in refugees. e present treatment guide should provide structured cooperation and optimism in apparently hopeless situations, which due to language di culties, trans-cultural features and serious mental illness, at least in the short term, seem to be unchangeable.

Due to the implementation of the treatment concept, from the perspective of the nursing sta , there is a noticeable relief and signi cant improvement concerning the interaction with refugees in the mental health unit. In particular the “Starter packet” o ers safety for the nursing sta as well as for the patients and alleviates the admission process and also the treatment process. e framework of the treatment concept o ers both, grounding and liberties. e successful establishment of transcultural supervision has promoted the whole treatment team to sensitize and work on the issue “ ight from warfare and mental health”. Treatment and care for the refugee patients could be simpli ed and improved because of better communication due to supporting of interpretation services, clear agreements by the help of the “Starter packet” and a better comprehension of the individual life circumstances of refugees and the resulting possible actions with the aid of the transcultural supervision. Furthermore, we have experienced that handling patients according to this treatment concept has mutually in uenced both, the treatment outcome of refugees as well as the clinical setting. It became possible not only to integrate refugees on a mental health unit but the process opens the way for reciprocal exchange between treatment team, refugees and other patients in terms of acculturation.

In the future we aim to establish speci c group-oriented psychotherapy for refugees, in addition to individual treatment.

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Currently we have coworkers (psychologists, physicians, nurses, social workers) from various countries (Turkey, Serbia, Russia, Iran, Eritrea) and we are continuing to hire clinicians from di erent ethnic and religious backgrounds to assist with the treatment of traumatized refugees. e establishment of a psychosocial and psychotherapeutic center for a central contact with core competencies in consultation, treatment, prevention, research, coordination, continuing education and linking supply structures for vulnerable refugees is planned to improve further care structures and interfaces between outpatient and inpatient treatment. is can provide the basis for a model of systematic and individualized care for refugees according to the broad framework of actual needs for treatment.


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Volume 7 • Issue 3 • 1000307


Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307


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  3. Hanewald B, Gieseking J, Vogelbusch O, Markus I, Gallhofer B, et al. (2016) Asylum law and mental health: An interdisciplinary analysis of the co-action of medical and legal aspects. Psychiatr Prax 43: 165-171.

  4. Preitler B (2013) Psychotherapy with seriously traumatized Chechen refugees. In: Feldmann RE, Seidler G (Eds.), Dream (a) Migration, Psychosocial Publishing.

  5. Keilson H (2005) Sequential trauma in children: Investigation into the fate of Jewish war swords. Psychosocial publishing house, Giessen.

  6. Steel Z, Silove D, Brooks R, Momartin S, Alzuhairi B, et al. (2006) Impact of immigration detention and temporary protection on the mental health of refugees. Br J Psychiatry 188: 58-64.

  7. Johnson H, Thompson A (2008) The development and maintenance of post- traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. Clin Psychol Rev 28: 36-47.

  8. Morina N, Maier T, Schmid Mast M (2010) Lost in translation? Psychotherapy using interpreters. Psychother Psych Med 60: 104-110.

  9. Stompe T (2009) Chronic depression among migrants. Spectrum Psychiatry 1: 22-24.

  10. UNHCR (2017) Culture, context and mental health of Somali refugees.

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35. Hofmann A, Luber M (2010) The absorption technique. In: Luber M (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations. Springer Publishing Co., New York, NY, USA.

36.Knipe J, Luber M (2010) The method of constant installation of present orientation and safety (CIPOS). In: Luber M (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations. Springer Publishing Co., New York, NY, USA.

37. Horowitz MJ, Wilner N, Alvarez W (1979) Impact of event scale: A measure of subjective stress. Psychosom Med 41: 209-218.

38. Putnam FW, Chu JA, Dill DL (1992) The dissociative experiences scale: Reply. Amer J Psychiatry 149: 143-144.

39. www.bamf.de/SharedDocs/Anlagen/DE/Downloads/Infothek/Statistik/Asyl/ statistik-anlage-teil-4-aktuelle-zahlen-zu-asyl.pdf?__blob=publicationFile 

*Corresponding author: Bernd Hanewald, Justus Liebig Universitaet Giessen, Centre for Psychiatry and Psychotherapy, Klinikstrasse 36, Giessen, Hesse 35392, Germany, Tel: +4964198545755; E-mail: bernd.hanewald@psychiat.med.uni-giessen.de

Received April 22, 2017; Accepted June 02, 2017; Published June 09, 2017

Citation: Hanewald B, Vogelbusch O, Heathcote A, Stapf-Teichmann F, Yazgan B, et al. (2017) A Concept of Clinical Care for Refugees on a General Psychiatric Ward. J Psychol Psychother 7: 307. doi: 10.4172/2161-0487.1000307

Copyright: © 2017 Hanewald B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


June 30th, 2017

It’s just a nightmare…

Imagine you're driving around at 2 a.m., hearing loud yelling and screaming coming from a house in front of you … then a gunshot and SILENCE ... then you find yourself in a car accident with the driver pinned in his car, followed by a scene of a depressed man with a gun in his hand. Would you stop and find out what’s going on?As a community, we are fortunate to have an excellent task force such as our local police department to protect us 24/7.Police officers have to go through extensive testing and training to be eligible for the police academy to be sworn in as police officers, and later to continue rigorous training to specialize and expand their roles in protecting and serving the community.Police officers are here to protect our community from potential risks and dangers at various levels: natural disasters, major accidents, drownings, domestic violence, traffic violations, disturbances of any sort. Call 911 and a police officer will show up to “protect and serve.”I have wondered what it takes to be a “good cop”: bravery, integrity, honesty, a drive to do the best to serve a community? Certaibravery, integrity, honesty, a drive to do the best to serve a community? Certainly not everyone would have the psychological, physical and emotional stamina to make it even through one ride-along. Cops risk their lives every day, even a minor traffic stop can result in major injury or even death; entering a home on a domestic violence call, not knowing what to expect, can be fatal; counseling and saving suicidal individuals; taking charge in hostage situations; peeling kids out of cars after accidents, rescuing and resuscitating drowning victims; stopping the speeding high school kid, only to give him the lecture without citation; educating kids about the dangers of alcohol and drugs; helping kids in CPS situations; rescuing kids and animals from overheated cars; honoring their peers and supporting their families in times of need. There are numerous occasions we should be thankful to have people out there who “protect and serve,” risking their lives and doing a job that most of us may marvel over watching a movie, however, not fully understanding what it takes to be a “good cop.” I hope we can all stop stereotyping the bad rap about cops and what a poor job they do. The fact is, most of them do amazing work, every day, protecting our community, risking their lives.


June 23rd, 2017

"The fruit of the Spirit is love, joy, peace, patience, kindness, generosity, faithfulness, gentleness and self-control" (Galatians 5:22). As we enthusiastically embrace new opportunities for self-improvement, focusing on more exercise, nutritious meals, financial goal-setting, etc., we often miss the big picture of psychological growth and well-being. Some individuals seem to have lost their fruit of spirit, appearing disgruntled, unhappy, insensitive and crabby. Statistically, about one in five individuals meet criteria for depression, anxiety or other illnesses that are frequently undetected even with frequent visits to a primary care physician. Physical symptoms such as headaches, stomach problems and aches and pains, are often "masked" symptoms of depressive or anxiety relate disorders that only a skilled mental health professional will detect. Although medication will temporarily present some relief for these ailments, they frequently return or are replaced by different symptoms. Often times, some physicians recognize the possibility of depression or anxiety and begin a regiment of psychotropic medication that may be helpful or not and, even worse, bring along side effects that make life even more uncomfortable for the individual. Sooner or later, some people find themselves with a "medication cocktail" that has not shown an improvement in quality of life, but created another, difficult to manage "monster." The same goes for children who are often mis-diagnosed and treated for various illnesses such as ADHD (Attention Deficit Disorder with Hyperactivity) and anger management or behavioral problems. If you or your physician has concerns regarding your or your child's mental health (or your child's development), ask for a referral to a psychologist. Once you have a referral, be a wise consumer by gathering information regarding the psychologist's credentials and orientation. Most psychologists are well-trained to assess, diagnose and treat various mental health concerns coinciding with the DSM-V (Diagnostic and Statistical Manual of Mental Disorders); psychological treatment should be research-based and explained to the patient prior to initiating the process. A psychiatrist can also diagnose the spectrum of mental illnesses and has a medical degree with residency in psychiatry and also has prescription privileges. Treatment primarily focuses on medication management, including side effects and successful pharmacological treatment of psychiatric illnesses, such as depression and anxiety. A clinical psychologist receives five years (Ph.D. or Psy.D.) of post bachelor training in all facets of mental health (child development, psychological assessment/testing, diagnosis and treatment), including a year internship and additional post-graduate training; only after close supervision of another licensed psychologist for a year and rigorous testing and examination via the Arizona Board of Psychologist Examiners, is licensing granted. There are many specialties in psychology, such as pediatric/family, neuropsychology and some psychologists prefer teaching at universities and pursue a career in research. As a wise consumer and educated individual, acknowledging the existence of mental health issues, the choice for a mental health professional is a very important one and vital for psychological growth and improvement; there are no "quick fixes" and remedies when it comes to mental health concerns and medication should be a last resort and not a first choice; consulting with a psychologist could be an important first step in recovering the "fruit of the spirit."




October 5, 2016

Autism spectrum disorders have increased dramatically over the past few decades, the U.S. Center for Disease Control and Prevention (CDC 2012) recently established the prevalence to be 1 in 88 American children and estimated 1 out of 54 boys being diagnosed with Autism. ASD affects over 2 million individuals in the U.S. and is one of the fastest growing mental health concerns. As of today, nobody can explain the exponential increase; there is stipulation that there is strong genetic involvement, due to the fact that it affects boys much more frequently than girls and tends to run in families. There is also speculation about risk factors that include advanced parental age (fathers and mothers) and maternal illness during pregnancy, however not one single factor has been determined to “cause autism”. Autism is a neuro-developmental condition and establishes its pathway early during fetal development and may alter parts of the developing infant brain.  Recent research has concluded that the brain of the child with autism is larger and that parts of it develop faster (e.g.,amygdala which helps control emotions).

Symptoms of autism can range from the inability to articulate wants and needs (limited or no language skills) to subtle difficulty with social situations; people with autism often have many strengths, including the ability to excel in visual skills, music, math and art.

Early diagnosis and intervention are the key and may improve quality of life and social adjustment, including success in school, college and place of employment.

Check ups with the pediatrician should include assessment of gross- and fine motor skills, language development, social interaction with care takers and children, and play skills. If your pediatrician recommends further assessment, or the parent seems concerned about the child’s development, an evaluation by a pediatric psychologist who specializes in autism may be indicative and helpful to rule out a diagnosis.

Some signs of autism are not noticed until a child enters school, as early development appeared normal and often precocious (early language development and reading skills); once a child enters preschool or kindergarten, specific signs of autism may be: intense focus on a specific subject (unusual knowledge of planets, dinosaurs etc), very formal language skills (I do not want to sleep during the day, for napping ); deficit in perspective taking (I don’t understand why other kids are not interested in planets); preferring  mature and solitary activities to play; seeking out familiar adults to spend free time activity with; excelling academically but showing difficulty with timed math or writing activities; sleep rhythm difficulties.

A diagnosis of autism is often a relief to the child and the parents who have wondered for a while “what’s wrong”.

I also suggest that we need to stop focusing  on “deficits” of the individual and all the things that a child can not do and shift our paradigm to “Neuro-diversity”: this means that we start viewing the individual with autism through the eye of human diversity. Each child with autism is unique as the rest of us and requires acceptance for a blend of cognitive strengths and weaknesses (language, sensory procession and motor skills). Early identification and subsequent treatment should focus on autism presenting contextual difficulties that could be avoided by giving each individual with autism unique and individual goals that will help him or her succeed. Sensory demands, social ambiguities and information complexities are some of the barriers that individuals on the autism spectrum have to conquer, however they need help from society.

As parents, professionals, fellow-human beings, educators and politicians the success of individuals with autism lies in accepting neuro-diversity and providing each of them with acceptance and tolerance, setting unique goals and teaching tools that help them succeed from early childhood into later adulthood. ( Come to think of it, that would include attention-deficit disorders as well).


What’s your EQ?


“No act of Kindness, no matter how small, is ever wasted” (Aesop)




We take great pride in sharing our intellectual intelligence with others, however it is also important to talk about Emotional intelligence (EI); or Emotional Quotient (EQ) meaning “the capacity of individuals to recognize their own, and other people's emotions, to discriminate between different feelings and label them appropriately, to use emotional information to guide thinking and behavior, and to manage and/or adjust emotions to adapt to interpersonal changes and goals.” (Goleman, 1995); Empathy is the key element of EQ and the feeling that you understand and share another person's experiences and emotions; the ability to share someone else's feelings.  (Merriam-Webster 2014).

There is ample research about high EQ and success in business: “Emotional Intelligence (EQ) will turbocharge your Career and Just might save your Life” (Forbes Contributor Travis Bradberry, March 2016)

Just eyeballing and not needing a Gallup survey, we live in a “selfie” society that focuses on self-serving achievement, competition and entitlement. We expect our children to share and show compassion, however as adults and leaders we are often not walking our talk and are pushing our kids into “survival of the fittest mode”.

Empathy is not only healthy for our emotional well-being, making us feel good but it also boosts our immune system and contributes to a healthier and happier human; it also calls for action and doing something to change something for the better; empathy can give us moral courage and do something positive, for example, not only giving a homeless person on the street a few dollars but volunteer at a food shelter or participate in making decisions about social change.

“It is one of the beautiful compensations of life that no man can sincerely try to help another without helping himself” (Ralph Waldo Emerson).

It is not too late for all of us to focus on caring and compassion, and most certainly pass that along to our children.  If we focused more on genuine empathy when we parent, we may end up having a generation of happier and more motivated individuals that are not only better at understanding themselves but others as well.

Much of our human interaction is disrupted by electronic devices, to the point where eye contact lasts for a split second, if even at all, really not enough time to even try to decipher another person’s facial expression, or show that you even care what someone may be feeling.

As a family, start making it a habit to share a simple meal, without electronic devices, play a new game: “name that facial expression and reteach detailed descriptions as to what that particular emotion entails”; or better yet, watch a baby’s behavior and describe in detail what he or she may be feeling.

The sooner we start paying attention to one another by showing true empathy, the sooner we will have less bullying in schools and more caring individuals who show moral courage and remind us all of what we have in common, being human!
Dr. Astrid Heathcote Licensed Psychologist
An ounce of prevention is a ton of cure…
The month of May marks National Children’s Mental Health Awareness (Substance Abuse and Mental Health Services Administration, SAMSHA, 2016) and it seeks to publicize the importance of children’s mental health is essential to a child’s healthy development from birth to adolescence. Needless to say that this would begin with childcare for infants that supports healthy emotional and cognitive development by keeping infant/caretaker ratio at a low level to ensure prompt and sensitive attention to a baby’s overall needs. However, careful attention may include the collaborative effort of parent(s) and school, starting with preschool and kindergarten, where formal education often begins with academic goals to prepare the child for the next grade. From a developmental perspective, keeping in mind the young child develops in some predictable and structured pattern, kindergarten can be very stressful for some children as their emotional needs cannot be met in a highly academic environment, resulting in a child who may appear to be “uncooperative and noncompliant” but is actually expressing anxiety and frustration. For the most part, public schools have to respond to producing high test scores, leaving teachers often unable to tend to social-emotional needs children have, adding “behavioral problems”, as another important agenda they have to deal with on a daily basis. By the time the child enters middle school, it may be poorly prepared to function in an even more stressful environment, not only academically but socially as well; young teens’ brains are a “work in progress” and social skills are poorly developed, coupled with exaggerated self-awareness, can result in an insecure child that feels isolated and lonely and if there is a lack of adult support, even trigger depression and/or anxiety. ALL Children across developmental milestones thrive on adult attachment and positive acknowledgement, reinforcing self-confidence and –worth and ultimately resulting in a well-adjusted and competent adult. As the high school years approach, some teens are excited about entering this new environment with hopefully a “clean slate” and finding friends and people who understand them. Nevertheless, high school presents yet another academically and socially stressful environment for some teens, who are ill equipped not only managing this intense setting but have acquired poor coping skills and ways to manage it (e.g. drugs and alcohol, sexually acting out). Teenager’s experience very profound changes: physically, mentally, psychologically, and emotionally and struggle to maintain a “balanced and healthy life style”; as parents, educators and administrators we must ask ourselves: “Are we raising mentally healthy and well-adjusted children to become responsible and independent adults?” Statistics speak for themselves, showing that 25% of American children meet criteria for a mental health concern (e.g . depression, anxiety) and many kids go without mental health care, because many adults assume “its just a phase” or “she will grow out of it”. As adults we must also assume the role of leadership and guide our children in learning to live a balanced life with a strong support system that provides an environment of genuine care and understanding, accepting and enjoying unique differences in EVERY child! Public schools and parents must become aware that WE teach a moral compass that kids accept and use to navigate life on a daily basis: does the punishment fit the crime? Schools and parents need to learn about child development from birth to adolescence to know what behaviors are “normal” and to guide the young person into feeling competent and successful. It is time for a change in the educational system that provides success for ALL children by providing individual education plans for each child and not by “cookie cutter academic goals” that have demonstrated poor outcomes for many children. ALL of us need to participate in sensitivity training to accept and enjoy unique differences in EVERYONE and not provide a confusing and contradictory moral compass to our young generation!

Topic of the week: 

PTSD can affect all of us

Imagine you just experienced a serious car accident without injuries and you are fully conscious, how would you respond to what just happened?

You may experience the after math of the accident, responding with high anxiety, even terror, cognitively (e.g. poor concentration), emotionally (e.g. feeling numb), physically (e.g. feeling lightheaded), and behaviorally (e.g. irritability). 

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V), “Acute Stress Disorder” is defined as “Exposure to actual or threatened death, serious injury, or sexual violation…learning that an event happened to a close relative or friend…experiencing repeated or extreme exposure to aversive details of a traumatic event(s) (e.g. first responders, such as police officers repeated exposure to details of child abuse)”.

 Symptoms of acute stress disorder  (a car accident for example) may be intense anxiety, confusion, rapid heart beat, intrusive memories of the event (nightmares or flashbacks of images of crashing into the other car), startling when hearing an ambulance drive by, anger or depression, altered sense of reality, and avoiding situations (such as driving a car). Often these symptoms will resolve within the first few weeks of the “trauma”, however if they persist past 30 days, the individual may meet criteria to be diagnosed with Posttraumatic Stress Disorder (PTSD) and should be evaluated by a psychologist, who specializes on trauma.

PTSD is a complex health condition that can develop in response to a traumatic experience – a life-threatening or extremely distressing situation that causes a person to feel intense fear, horror or a sense of helplessness. PTSD can cause severe problems at home or at work. Anyone can develop PTSD – men, women, children, young and old alike. Prevalence of PTSD ranges from 6.8% in the general population (NIMH, 2014) to 25% (PTSD.gov) among military veterans., and 35% among first responders (fire fighters) to the  September 11th tragedy.

Trauma is about perceived threat and not all individuals experiencing a life-threatening event end up with Acute Stress- or PTSD.

However, along with military veterans, first responders, such as fire fighters, EMTs and police officers have a higher risk in developing not only acute stress disorder, but also complex and delayed (symptoms surface 6 months after the trauma) PTSD, due to the frequency of involvement in detailed stressful events (deaths, injuries, domestic violence, child abuse etc.).

Untreated PTSD can have devastating consequences on the individual’s quality of life; not only does sleep become severely compromised, due to frequent nightmares about traumatic events, but often severe depression and anxiety set in; the individual with untreated PTSD may avoid social interactions and appear irritable and sometimes even explosive in their daily interactions with friends and family; his or her professional life may also be affected, because the individual may call in sick often, suffering from headaches, frequent colds and other illness, and exhaustion due to severe insomnia; he or she may avoid responding to specific job duties because they trigger more anxiety, even panic attacks.

Daily life becomes hopeless because added stressors, such as fighting with a spouse often related to substance abuse, can turn thoughts into a very dark place.

Fortunately, PTSD is not a life-long condition and very treatable via psychotherapy and sometimes medication can be helpful.

First responders are not very good about asking for help themselves; often they are noticed because of drastic performance changes at work (not responding to an emergency call, and/or displaying exaggerated aggressive behavior toward coworkers or while on duty).

On the home front, first responders with PTSD may become more and more socially withdrawn and appear “mentally checked out” or aggressive toward spouse and children; a spouse is frequently the first one to notice drastic changes in behavior, sleep patterns, and overall negative demeanor in their wife or husband.

I am urging not only spouses, friends or family members to encourage first responders to seek help for psychological assessment and treatment of PTSD, but also administrators, human resources and public policy to provide regular “checkups from the neck up” to all professionals who are first responders to emergency situations (Firefighters, EMTs, Police Officers etc.); it is time to stop stigmatizing utilization of mental health services to those who may need it the most but may never ask for it, resulting in a poor quality of life and also potential liability issues on the job.

If you think someone needs immediate mental health assistance call 911 or the nearest hospital emergency room.


Resources: ptsd.va.gov    ptsdalliance.org  nimh.nih.gov  samsha.gov