Mental Health Support For Refugees

2020
Gesa Solveig Duden
Mental Health Support for

Refugees – Integrating Brazilian
Perspectives
Mental Health Support
for Refugees – Integrating Brazilian
Perspectives
Dissertation
submitted to the Institute of Psychology,
University of Osnabrück, Germany
for the degree
Doktorin der Philosopie (Dr. phil.) - Doctorate of Philosophy
By
Gesa Solveig Duden
born in Bremen, Germany
Osnabrück, 2020
1st Prof. Dr. Dr. Josef Rogner (University

Supervisior of Osnabrück, Germany)
2nd Prof. Dr. Lucienne Martins-Borges

Supervisor (Université Laval, Canada &
Universidade Federal de Santa
Catarina, Brazil)
En 2014 encore, cinq millions cinq-cent-mille personnes ont fui leurs maisons
Forcées de se réfugier dans des villes, des pays loin de chez eux
Sans aucune idée du moment où ils pourraient retrouver leurs existences habituelles
Cinq millions cinq-cent-mille personnes ont fui leurs maisons, forcées de se réfugier
Né so
M'bitaa so
Né so
Home
Une maison, des habitudes, un futur
M'bitaa so
Where to place my dreams
Where to hold a heart opened to joy, opened to hope
Né bi taa so
En 2014 encore, cinq millions cinq-cent-mille nouveaux réfugiés

Cinq millions cinq-cent-mille réfugiés de plus
Encore au vingt-et-unième siècle de notre monde, tant de guerres, tant de victimes
Cinq millions cinq-cent-mille personnes ont fui leurs maisons
Forcées de se réfugier dans des villes, des pays loin, loin, de chez eux
Né so
Né bi taa so
Where to place my dreams
Where to hold a heart opened to joy, opened to hope
Né so
M'bitaa n'so
Né bi taa so
Tant de guerre, tant de victimes

Tant de tristesse, tant de désarroi
Tant d'espoir, tant d'espoir
Rokia Traoré, 2016
2
To all the participants. And their patients.
3
Acknowledgements
This doctoral thesis was supported by a generous research fellowship from the Hans-
Böckler-Stiftung, which also funded my extended research stay at the “Division of Transcultural
Psychiatry” at McGill University in Montréal.
While conceptualising and writing this thesis I have received a great deal of support from
many people. Indeed, it has been the work in a collective and network which has allowed me to
begin, conduct and finally, to finish this project.
I would first like to thank my two supervisors whose expertise has been invaluable. My
German supervisor, Josef Rogner, has supported me in all of my plans and projects, motivated me
and helped me not to lose sight of my goal. His reliability and positive comments have been a
source of encouragement and reassurance over these years. His literature recommendations have
inspired me and given me the opportunity to embed my ideas in new theoretical contexts. To my
Brazilian supervisor, Profa Lucienne, I express my deep gratitude for welcoming me so warmly in
her research divison “NEMPsiC” in 2015. The time I spent with her and my colleagues at this
division, as well as in Québec, has left a profound mark – on me personally, as well as on my
professional trajectory. Profa Lucienne has been a deeply committed mentor during my fieldwork,
a thorough support in the data analysis phase and a critical reader of my manuscripts. Furthermore,
she has put me in contact with wonderful people and projects throughout these years. Five years
have passed since our first contact, and I very much hope that this collaboration will continue for
much longer.
My thanks also go to all my friends and colleagues who facilitated this dissertation by pilot
testing the interview guidelines and assisting in the transcriptions and the coding of the interviews,
in particular: Luiza Marson Morais, Malena Rassmann, Paula Campos Andrade, Raphael Didjurgeit,
and Vagner Perez. Furthermore, many friends have been an enormous and patient help by
proofreading my manuscripts and providing their constructive feedback. Here I would like to pay
my special regards to Darragh O'Shea, Felicity Parker, Kosta Gligorijevic, Maria Heydel, Sabine
Sommer, Sofie de Smet and Yonas Tegegne.
I would further like to express my appreciation to all the participants and members of the
Platform for Social Research on Mental Health in Latin America (PLASMA), of the colloquium
AG Transcultural Psychiatry Charité Berlin, as well as of the Summer Programme in Social and
Cultural Psychiatry at McGill University, for being such a great inspiration and providing
welcoming spaces of discussion and exchange. Furthermore, I would like to thank the teams from
the Clínica Intercultural, Refugio Bremen and the NTFN; getting to know their work and being
able to contribute to it was one of the greatest motivations for writing this thesis.
4
Acknowledgements
Travelling, migrating and living in many places, I am deeply grateful to all the people that
have welcomed me, taken me in, volunteered as cultural mediators, become friends and thus made
this thesis possible: Alisson Vinícius Silva Ferreira, for his hospitality, language checks, our trips
and particularly for our inspiring conversations in the three-country-border city; Allyne Fernandes
Oliveira Barros, whose beautiful name has to find full appreciation here, for being a wonderful
colleague, companion and friend, for helping me to understand much of what felt strange at first
and for sharing many beautiful moments with me in two countries; Ana Sofia dos Santos Lima
Guerra, for her hospitability and great help to find participants, Andrey Borges Bernardes, for
connecting me to his country and family and for challenging me to think to the roots of things;
Francesco Galuppi for being a patient and motivating companion along the last meters of this
thesis; Gabriel Bueno, for always being in Floripa to welcome me and to say goodbye, for truly
listening, and for pretending to or actually enjoying a bike ride in 2°C to Nietzsche’s grave; Gernot
Gellwitz, for not only turning my kitchen into a kitchen, but also for giving me stability and
perspective; Gil Leal Caruso, for trusting me, for being my first connection to Floripa and to all
those wonderful people, for sharing the delights of language learning and for cooking a delicious
sweet potato; Hoschin Ibrahim, for a wonderful welcome in Leipzig, and for his joy and
unconditional help; Karinne Borges Bernandes and Alexandre Augusto de Paiva Barreiros for their
hospitality, understanding, and solidarity, and, together with Sam, for being strong pillars for me,
particularly during my first time in Brazil; as well as her whole family in Minas Gerais who took me
in and provided the most wonderful context in which to develop a tie to Brazilian realities and
learn a beautiful language; Mariá Boeira Lodetti for being an amazing host in Québec and helping
me to process the reviewers’ feedback I received in my life; Mohammed Abraham Builo for
showing me yet another reality and for his beautiful piano music; Nisse Silva for playing the part
of the best integration helper one could dream of, and for providing me with the possibility to
connect to the reality and to young people of the Sertão; Renan Blah and Mitsue Yanai, whose
apartment has been one of the most constant and most incredible places of home for me, and
whose choice of films motivated this thesis artistically; Robert Fiedler, for our Franco-Brazilian
exchanges and so many points of connection; Sandra Greifenhagen for swimming with me and
sharing saudades; Thiago Guedes Willecke, for helping with the data analysis and building a bridge
to Germany; Wiebke Koch and Marco Patzer, for their absolutely reliable friendship and for being
there and being a home in the most difficult times.
Additionally, I would like to express my deepest gratitude to nine women whose friendship
has been a layer of warmth, beauty and emotional connection throughout the years: Anna
Emmrich, Anna Helbig, Esther Blüthgen, Julia Flor, Lara Lamping, Maria Heydel, Rosa Palm,
Samanta Borges Pereira and Sophia Matschinsky.
5
Acknowledgements
I cannot go without acknowledging all the artists who have been faithful companions
throughout this work, helping me through the coding of difficult stories and through mundane
tasks, in particular Agnes Obel, Abacaxepa, Ana Tijoux, Arat Kilo, Baden Powell, BaianaSystem,
El Sono Sono, Ezra Collective, ‫فيروز‬, Fatoumata Diawara, Gaël Faye, Geraldo Azevedo, Gotan
Project, Kokoroko, Kolinga, Luedji Luna, ‫مشروع ليلى‬, Mayra Andrade, Molly Johnson, Mop Mop,
Muddy Waters, Nicola Cruz, Nightmares On Wax, Parov Stelar, Philip Glass, Rokia Traoré,
Y’akoto, Zoë Keating and many more. My thanks also go to all the dancers I was so lucky to dance
with while writing my thesis, as these have kept me moving, connected and happy, especially the
CIA in Petrolina, Pernambuco and all the Swing and Blues dancers in Berlin, Bremen, Dublin,
Leipzig, Montréal, Osnabrück and Paris.
My eternal thanks go to my parents Silke Duden and Rolf Altenburger, and to my brother
Sven Altenburger who have always been there for me with their love, unconditional support, and
humour. My confidence in exploring, my curiosity and my appreciation of cultures, languages and
human connections are the result of growing up in such an encouraging, reflective and secure
setting, and of feeling my family’s unchanging trust.
Finally, I would like to express my deepest appreciation to all the research participants who
have confided in me and who took the time and energy to take part in the various studies that went
into this dissertation. Without them this thesis would not exist. I hope that with this work I can
make a modest contribution to their efforts in the mental healthcare of immigrants and refugees,
and ultimately to the well-being of their patients.
Gesa
Leipzig, October 2020
6
Agradecimentos
Esta tese de doutorado foi apoiada por uma bolsa de pesquisa da Hans-Böckler-Stiftung,
que também financiou minha estadia na “Divisão de Psiquiatria Transcultural” da Universidade
McGill em Montréal.
Ao longo da construção e redação desta tese, recebi apoio de muitas pessoas. De fato, o
que me permitiu começar, continuar e, finalmente, terminar este projeto, foi o trabalho coletivo e
em rede.
Em primeiro lugar, gostaria de agradecer aos meus dois orientadores, cujas experiências
têm sido inestimáveis. Meu supervisor alemão, Josef Rogner, me apoiou em todos os meus planos
e projetos, me motivou e me ajudou a não perder de vista o meu objetivo. Sua confiança em meu
trabalho e seus comentários positivos sempre foram um raio de esperança e me reconstruíram ao
longo destes anos. As recomendações de literatura me inspiraram e me deram a oportunidade de
incorporar novos contextos teóricos. À minha supervisora brasileira, Profa Lucienne, tenho que
expressar minha profunda gratidão por me receber tão calorosamente em seu núcleo de pesquisa
“NEMPsiC” em 2015. O tempo que passei com ela e meus colegas, assim como em Québec, deixou
marcas significativas - em mim e em minha trajetória profissional. Profa Lucienne foi uma mentora
intensamente comprometida durante meu trabalho de campo, um apoio minucioso na fase de
análise de dados e uma leitora crítica dos meus manuscritos. Além disso, ela me colocou em contato
com pessoas e projetos maravilhosos ao longo destes anos. Cinco anos se passaram desde nosso
primeiro contato e espero que esta nossa colaboração continue por muito tempo.
Meus agradecimentos também vão para os amigos e colegas que facilitaram esta tese,
participando do teste piloto do roteiro de entrevista e auxiliando nas transcrições e codificações
das entrevistas, em particular: Luiza Marson Morais, Malena Rassmann, Paula Campos Andrade,
Raphael Didjurgeit e Vagner Perez. Além disso, muitos amigos têm oferecido uma ajuda enorme e
paciente ao revisarem meus manuscritos e fornecerem seus feedbacks construtivos. Um especial
agradecimento a Darragh O'Shea, Felicity Parker, Kosta Gligorijevic, Maria Heydel, Sabine
Sommer, Sofie de Smet e Yonas Tegegegne.
Gostaria ainda de expressar meu apreço a todos os participantes e membros da Plataforma
de Pesquisa Social em Saúde Mental na América Latina (PLASMA), do colóquio AG Psiquiatria
Transcultural Charité Berlin, bem como do Programa de Verão em Psiquiatria Social e Cultural da
Universidade McGill, por serem uma inspiração e proporcionarem espaços calorosos de discussão
e intercâmbio. Além disso, agradeço às equipes da Clínica Intercultural, Refúgio Bremen e NTFN;
7
Agradecimentos
conhecer seus trabalhos e poder contribuir com eles foi uma das maiores motivações para escrever
esta tese.
Viajando, migrando e vivendo em muitos lugares, sou profundamente grata a todas as
pessoas que me receberam, me acolheram, se voluntariaram como mediadores culturais, tornaram-
se amigos e assim, tornaram esta tese realmente possível: Alisson Vinícius Silva Ferreira, por sua
hospitalidade, pelas correções ortográficas, por nossas viagens e particularmente por nossas
conversas inspiradoras na cidade fronteiriça de três países; Allyne Fernandes Oliveira Barros, cujo
belo nome deve ser devidamente reconhecido, por ser uma maravilhosa colega, companheira e
amiga, me ajudando a entender o que me pareceu estranho no início e por compartilhar comigo
muitos momentos bonitos em dois países; Ana Sofia dos Santos Lima Guerra, por sua hospitalidade
e sua grande ajuda para encontrar participantes, Andrey Borges Bernardes, por me conectar com
seu país e sua família e me incentivar a pensar nas raízes das coisas; Francesco Galuppi, por ser um
companheiro paciente e motivador na reta final desta tese; Gabriel Bueno, por estar sempre em
Floripa para me receber e se despedir de mim, pela escuta atenta, e por fingir ou realmente curtir
fazer um passeio de bicicleta a 2°C até a sepultura de Nietzsche; Gernot Gellwitz, não só por
transformar minha cozinha em uma cozinha, mas também por me possibilitar estabilidade e
perspectiva; Gil Leal Caruso, por confiar em mim, por ser minha primeira conexão com Floripa e
com todas aquelas pessoas encantadoras, por compartilhar a alegria de aprender idiomas e cozinhar
uma batata doce deliciosa; Hoschin Ibrahim, pela radiante recepção em Leipzig, por sua alegria e
ajuda incondicional; Karinne Borges Bernandes e Alexandre Santos, por sua hospitalidade,
compreensão e solidariedade e, junto com Sam, por serem fortes pilares para mim, particularmente
durante minha primeira estadia no Brasil; assim como toda sua família em Minas Gerais, que me
acolheu e proporcionou o mais maravilhoso contexto para desenvolver vínculo com as realidades
brasileiras e aprender uma bela língua; Mariá Boeira Lodetti, por ser uma anfitriã formidável em
Québec e me ajudar a processar as primeiras revisões de um artigo que recebi em minha vida;
Mohammed Abraham Builo por me mostrar mais uma realidade que existe neste mundo e por sua
bela música para o piano; Nisse Silva, por assumir o papel da melhor ajudante de integração que se
poderia sonhar e por me proporcionar a possibilidade de me conectar com a realidade e com os
jovens do Sertão; Renan Blah e Mitsue Yanai, cujo apartamento tem sido um dos mais constantes
e incríveis lugares de refúgio para mim, e cuja escolha de filmes motivou artisticamente esta tese;
Robert Fiedler, por nossos intercâmbios franco-brasileiros e tantos pontos de conexão; Sandra
Greifenhagen por nadar comigo dividindo saudades; Thiago Guedes Willecke, por ajudar com a
análise de dados e construir uma ponte com a Alemanha; Wiebke Koch e Marco Patzer, pela
amizade absolutamente segura, por estarem presentes e por serem um lar nos momentos mais
difíceis.
8
Agradecimentos
Além disso, gostaria de expressar minha mais profunda gratidão a nove mulheres cuja
amizade tem sido uma camada de calor, beleza e conexão emocional ao longo dos anos: Anna
Emmrich, Anna Helbig, Esther Blüthgen, Julia Flor, Lara Lamping, Maria Heydel, Rosa Palm,
Samanta Borges Pereira e Sophia Matschinsky.
Não posso deixar de reconhecer todos os artistas que têm sido companheiros fiéis ao longo
deste trabalho, ajudando-me através de histórias difíceis e tarefas mundanas, em particular Agnes
Obel, Abacaxepa, Ana Tijoux, Arat Kilo, Baden Powell, BaianaSystem, El Sono Sono, Ezra
Collective, ‫فيروز‬, Fatoumata Diawara, Gaël Faye, Geraldo Azevedo, Gotan Project, Kokoroko,
Kolinga, Luedji Luna, ‫مشروع ليلى‬, Mayra Andrade, Molly Johnson, Mop Mop, Muddy Waters,
Nicola Cruz, Nightmares On Wax, Parov Stelar, Philip Glass, Rokia Traoré, Y’akoto, Zoë Keating,
e tantos outros. Meus agradecimentos também vão para todos os dançarinos com quem tive a sorte
de dançar durante o tempo em que escrevi minha tese, pois estes me mantiveram em movimento,
conectada e feliz, especialmente a CIA em Petrolina, Pernambuco e todos os dançarinos de Swing
e Blues em Berlim, Bremen, Dublin, Leipzig, Montréal, Osnabrück e Paris.
Meus eternos agradecimentos vão para meus pais Silke Duden e Rolf Altenburger, e para
meu irmão Sven Altenburger que sempre estiverem presentes com seu amor, apoio incondicional
e humor. Minha confiança para explorar, minha curiosidade e minha apreciação das culturas,
línguas e conexões humanas são o resultado de crescer em um contexto tão encorajador, reflexivo
e seguro, e de sentir a confiança imutável de minha família.
Finalmente, gostaria de expressar meu profundo apreço a todas e todos participantes da
pesquisa que confiaram em mim e que dedicaram tempo e energia para participar dos vários estudos
desta pesquisa. Sem eles e elas, esta tese não existiria. Espero que com este trabalho eu possa
contribuir um pouco para apoiar seus esforços no cuidado em saúde mental de imigrantes e
refugiados e, finalmente, para o bem estar de seus pacientes.
Gesa
Leipzig, outubro de 2020
9
Abstract
Refugees show higher prevalence of psychological disorders compared to the general
population in host countries. At the same time, there is a lack in the provision of and knowledge
about appropriate transcultural mental health support. The overall goal of this thesis was to
investigate insider perspectives on the mental health support for refugee patients (MHSR). More
specifically, the objective was to obtain insights into the MHSR in Brazil, a Latin-American and
developing country. The research on refugees in Brazil is sparse, but the need to provide adequate
MHSR is increasing with growing numbers of people who seek refuge in the country.
The goal was approached in the first section of this thesis by reviewing and synthesising
the existing research. In this, we aimed at obtaining insights into qualitative research findings on
the perspectives of professionals and refugee patients concerning MHSR. The section starts with
Chapter 2, a qualitative evidence synthesis of ten primary qualitative studies referring to 145 insider
perspectives. The main findings highlight the importance of a trusting therapeutic relationship, of
the adaptation of therapeutic approaches to patients’ needs and situation, and of psycho-social
support, cultural sensitivity, as well as of external support structures for professionals. Negative or
hindering aspects were identified as a lack of mental healthcare structures, the impact of the post-
migration situation on patients’ well-being, cultural and language differences, and patients’ mistrust.
Finally, ambivalences were formulated regarding verbal therapies, trauma exposure, the use of
mental healthcare, and the impacts of the work with refugees on professionals. Section I ends with
Chapter 3, that critically evaluates the method of a qualitative evidence synthesis and discusses
some of its challenges, particularly with regard to the question of how to abstract and merge
primary qualitative results without losing their in-depth-meaning. Chapter 3 also poses the question
of the universality of the findings of the QES, as no primary studies from non-Western countries
were included. The need for a greater international plurality in the research field of MHSR
motivates Section II of this thesis.
This second section looks at how psychologists in Brazil perceive the MHSR in this Latin-
American country. Three different studies were performed for this second section using qualitative
semi-structured interviews with professionals and thematic analysis, as well as consensual
qualitative research strategies. The first study investigated how psychologists perceive the
psychological suffering and symptoms of their refugee patients. It also provides background and
contextual information for the following parts, such as concerning refugee patients’ countries of
origin. The investigation found that the most frequently described conditions in refugee patients
were anxiety and depression disorder and symptoms, grief, and PTSD symptoms. However, the
results also showed that the use of manuals for the categorical classification and diagnosis of mental
10
Abstract
disorders is a debated topic among psychologists in Brazil, since psychiatric diagnostic categories
are often perceived to be a poor representation of a person’s experience. Psychologists tended to
stress patients’ socio-political suffering and to conceptualise patients’ symptoms as expected
reactions to their profound losses and ongoing contextual instability. Participants discussed
refugees suffering especially in relation to four clusters: the postmigration stressors, traumatic
experiences, flight as life rupture, and the current situation in the country of origin.
The second study of Section II explored the perspectives of psychologists on providing
“acolhimento psicológico” (psychological care) for refugees in Brazil. It analysed the general
experiences, positive and negative aspects, as well as facilitators and necessary changes to better
the MHSR. Results showed, that psychologists experienced operating in a novel, precarious and
xenophobic context, which led them to move beyond classical psychological work, engage in
practical assistance and become very close to clients. Participants reported on a lack of public
structures, insufficient competencies of professionals and high levels of staff fatigue. At the same
time, they described gaining new perspectives and benefiting from witnessing their clients’
resilience. In terms of facilitating factors for the psychological care process participants pointed to
the importance of psychologists being flexible, authentic, of showing a high resistance to
frustration, and of making use of group-based approaches. Participants suggested that, in order to
better refugees’ mental health in Brazil, efforts should focus on adopting a more social perspective
in psychology, developing antidiscrimination campaigns, building policies for refugee’ integration,
and scaling up investments in mental healthcare in general.
The third study of Section II, retrieved the psychotherapists’ experience of providing
psychotherapy for refugees in Brazil. Supportive and hindering elements in psychotherapy with
refugee patients in Brazil were identified at eight different levels: the patient, the therapist, their
relationship, the setting, the psychotherapeutic approach, the context of the patient, the context of
the therapist and the societal context in Brazil. Hindering elements in the therapy included missing
preparation for the integration of refugees, lack of interpreters, patients’ mistrust and therapists
feeling untrained, helpless and becoming overinvolved. Supportive elements included a trusting
therapeutic relationship, therapists’ cultural humility and structural competence, patients’ societal
inclusion as well as working with groups and networks. This investigation showed that in light of
the enormous structural challenges for the mental well-being of refugee patients, therapists’
flexibility and the reliance on collective work and networks of support is crucial.
Finally, Section III, the integrative discussion summarizes, compares and contrasts the
results of the various studies of this dissertation regarding, again, helpful/positive, ambivalent, and
supportive/negative factors in the MHSR. These synthesised results are subsequently embedded
11
Abstract
within and discussed in relation to the scientific literature. The thesis closes by considering its
limitations and by providing suggestions for future research, as well as an overall conclusion.
12
Resumo
A saúde mental de refugiados deve ser uma temática cuidadosamente investigada visto o
aumento da vulnerabilidade psíquica decorrente de fatores pré-migratórios, como as experiências
traumáticas no contexto de guerras, violências extremas, perseguições; e fatores pós-migratórios,
como a insegurança relacionada ao status legal, a falta de estruturas de acolhimento e a perda das
referências culturais. Em vários países, é possível identificar modalidades de acompanhamento
psicoterapêutico voltadas aos refugiados, comparações entre técnicas específicas para o tratamento
de quadros traumático e investigações quantitativas da eficácia de tipos de tratamento. Ao mesmo
tempo, sabe-se pouco sobre as experiências dos atores principais dessas terapias - os refugiados e
os psicólogos. O objetivo geral desta tese foi o de investigar experiências referentes ao
acompanhamento em saúde mental de pacientes refugiados (MHSR). Mais especificamente, melhor
compreender esta realidade, isto é a MHSR no Brasil, um país latino-americano e em
desenvolvimento. A pesquisa sobre refugiados no Brasil é escassa, mas a necessidade de fornecer
MHSR está aumentando com o número crescente de pessoas que buscam refúgio no país.
Assim, a primeira seção desta tese apresenta os resultados de pesquisas existentes sobre a
percepção de profissionais e de pacientes refugiados do apoio à saúde mental ofertada aos
refugiados (MHSR). Ela consiste em uma síntese qualitativa (Qualitative Evidence Synthesis) de
dez estudos qualitativos primários que englobam, no total, 145 participantes. Os principais
resultados destacaram a importância da relação terapêutica baseada na confiança, da adaptação das
técnicas terapêuticas e do apoio psicossocial às especificidades de pacientes refugiados, da
sensibilidade cultural e das estruturas externas de apoio aos profissionais. Aspectos negativos ou
obstáculos também foram identificados, como a falta de instituições de atenção à saúde mental, o
impacto da pós-migração no bem-estar dos pacientes, as diferenças culturais e linguísticas e a
desconfiança dos pacientes. Finalmente, foram observadas ambivalências em relação à expressão
verbal de sentimentos, à exposição terapêutica às experiências traumáticas, ao benefício da
psicoterapia para pacientes refugiados e aos impactos provocados por este trabalho nos
profissionais. A Seção I termina com um capítulo que discute o método de pesquisa “Qualitative
Evidence Synthesis” e apresenta alguns de seus desafios, particularmente no que diz respeito à
questão de como promover a inclusão de pesquisas primárias de uma maior pluralidade
internacional.
A Seção II da tese apresenta os resultados da investigação sobre a percepção dos psicólogos
brasileiros do apoio à saúde mental dos refugiados no Brasil. Esta segunda seção consiste em três
estudos diferentes. O primeiro estudo investigou como os psicólogos percebem o sofrimento
psicológico e os sintomas de seus pacientes refugiados. Este estudo também fornece informações
13
Resumo
básicas e contextuais para as partes que seguem, como os países de origem mais frequentes dos
pacientes refugiados. Foi possível observar que as condições mais descritas por pacientes
refugiados foram os transtornos e sintomas de ansiedade, transtornos e sintomas depressivos, luto
e sintomas de estresse pós-traumático. Entretanto, os resultados também mostraram que o uso de
manuais para a classificação dos transtornos mentais é um tema amplamente debatido entre
psicólogos no Brasil, particularmente pelo fato de que as categorias diagnósticas dos transtornos
mentais são frequentemente percebidas como insuficientes para representar a experiência de uma
pessoa. Os psicólogos chamam a atenção para o sofrimento sócio-político dos pacientes e tendem
a compreender os sintomas dos pacientes como reações consequentes de suas perdas profundas e
da instabilidade contextual contínua. Os participantes identificaram o sofrimento dos refugiados
baseado, principalmente, em quatro fatores: os fatores de estresse pós-migração, as experiências
traumáticas, a fuga como ruptura da vida e a situação atual no país de origem.
O segundo estudo da Seção II investigou as experiências de psicólogos no acolhimento
psicológico de refugiados no Brasil. O estudo analisou as experiências globais, aspectos positivos
e negativos, assim como facilitadores e mudanças necessárias para melhorar o MHSR. Os
resultados mostraram que os psicólogos passaram a operar em um contexto novo, precário e
xenófobo, o que os levou a ir além do trabalho clínico tradicional, a se engajarem em uma ações
sociais e a se tornarem mais íntimos das pessoas atendidas. Os profissionais relataram falta de
estruturas públicas, competências insuficientes e altos níveis de “Burnout”. Ao mesmo tempo,
descreveram efeitos positivos como a conquista de novas perspectivas e a possibilidade de
testemunhar da resiliência de seus clientes. Em termos de facilitadores, os participantes apontaram
para a importância de professionais serem flexíveis, autênticos, demonstrarem uma alta tolerância
à frustração e fazerem uso de abordagens grupais. Os participantes sugeriram que, a fim de
melhorar a saúde mental dos refugiados no Brasil, os esforços devem se concentrar na adoção de
uma perspectiva de uma psicologia mais social, desenvolvendo campanhas de anti-discriminação,
construindo políticas para a integração de refugiados e ampliando os investimentos em saúde
mental.
O terceiro estudo da Seção II, constitui um estudo sobre a experiência dos psicólogos na
oferta da psicoterapia para refugiados no Brasil. Elementos de apoio e obstáculos para a
psicoterapia com pacientes refugiados no Brasil foram identificados em oito diferentes níveis: o
paciente, o terapeuta, a relação terapêutica, o setting, a abordagem psicoterápica, o contexto do
paciente, o contexto do terapeuta e o contexto social no Brasil. Os elementos que dificultaram a
psicoterapia incluíram a falta de preparo para a integração dos refugiados, a ausência de intérpretes,
a desconfiança dos pacientes e os professionais que se sentiam sem preparo para este trabalho,
desamparados e, por conseguinte, se tornavam excessivamente envolvidos com a situação.
14
Resumo
Elementos de apoio incluíram uma relação terapêutica baseada na confiança, bem como a
humildade cultural e a competência estrutural dos psicólogos, a inclusão social dos pacientes, assim
como o trabalho em grupos e em redes. Este estudo mostrou que, em função dos enormes desafios
estruturais necessários ao bem-estar mental dos pacientes refugiados, a flexibilidade dos terapeutas
e a confiança no trabalho coletivo e nas redes de apoio é crucial.
Finalmente, na Seção III, foi apresentada a discussão integrativa desta tese que resume,
compara e contrasta os resultados dos vários estudos em relação a fatores positivos, ambivalentes
e negativos no MHSR. Estes resultados sintetizados são subsequentemente incorporados e
discutidos com a literatura científica. A tese se encerra com a apresentação de suas limitações e de
sugestões para futuras pesquisas.
15
Zusammenfassung
Die psychische Gesundheit von geflüchteten Menschen bedarf besonderer
Aufmerksamkeit aufgrund der erhöhten psychischen Vulnerabilität, die auf Faktoren vor der
Migration zurückzuführen ist, wie z.B. traumatische Kriegserlebnisse, extreme Gewalt, Verfolgung
usw., sowie auf Faktoren nach der Migration, wie z.B. unsicherer Aufenthaltsstatus, fehlende
Integrationsstrukturen und Verlust kultureller Bezüge. International finden sich verschiedene
Beschreibungen von Ansätzen zur psychotherapeutischen Behandlung von Geflüchteten,
Vergleiche zwischen Therapieformen insbesondere in Bezug auf Traumatherapie und quantitative
Untersuchungen zur Effizienz von Behandlungsformen. Gleichzeitig ist wenig über die
Erfahrungen der Hauptakteure dieser Therapien – geflüchtete Patient:innen und Psycholog:innen
– bekannt. Daher war das übergeordnete Ziel dieser Dissertation die Untersuchung von
Insiderperspektiven auf die psychosoziale Behandlung von Patient:innen mit Fluchterfahrungen
(„mental health support for refugee patients“, MHSR). Das spezifischere Ziel war es, Einblicke in
die MHSR in Brasilien, einem lateinamerikanischen Entwicklungsland, zu gewinnen und in die
internationale Forschungsliteratur zu integrieren. Die Forschung über Geflüchtete in Brasilien ist
spärlich, aber die Notwendigkeit, angemessene MHSR zu entwickeln und bereitzustellen, nimmt
mit der wachsenden Anzahl von Menschen, die in diesem Land Zuflucht suchen, zu.
Teil I dieser Arbeit war darauf ausgelegt, Einblicke in bestehende Forschungsergebnisse
über die Perspektiven von Fachkräften und geflüchteten Patient:innen auf die psychosoziale
Behandlung von Geflüchteten (MHSR) zu gewinnen. Die Studie besteht aus einer qualitativen
Evidenzsynthese („Qualitative Evidence Synthesis“) von zehn qualitativen Primärstudien, die sich
auf 145 Insiderperspektiven beziehen. Die Hauptergebnisse unterstreichen die Bedeutung einer
vertrauensvollen therapeutischen Beziehung, der Anpassung der therapeutischen Ansätze an die
Bedürfnisse und die Situation der Patient:innen sowie der Notwendigkeit einer psychosozialen
Unterstützung, kulturellen Sensibilität und von externen Unterstützungsstrukturen für Fachkräfte.
Als negative oder behindernde Aspekte wurden ein Mangel an Strukturen der psychosozialen
Versorgung, die Auswirkungen der Postmigrationssituation auf das Wohlbefinden der
Patient:innen, kulturelle und sprachliche Unterschiede und das Misstrauen der Patient:innen
genannt. Schließlich wurden Ambivalenzen formuliert in Bezug auf verbale Therapien,
Traumaexpositionsverfahren, dem Nutzen von Psychotherapie und die Auswirkungen dieser
Arbeit auf die Fachkräfte. Teil I schließt mit Kapitel 3, in dem die Methode „Qualitative Evidence
Synthesis“ kritisch bewertet und einige ihrer Herausforderungen diskutiert werden, insbesondere
im Hinblick auf die Frage, wie primäre qualitative Ergebnisse abstrahiert und zusammengeführt
werden können, ohne ihre tiefere Bedeutung zu verlieren. Kapitel 3 wirft auch die Frage nach der
16
Zusammenfassung
Universalität der Ergebnisse der QES auf, da keine Primärstudien aus nicht-westlichen Ländern
einbezogen wurden. Die Notwendigkeit einer größeren internationalen Pluralität im
Forschungsfeld der MHSR motiviert den Teil II dieser Arbeit.
Dieser zweite Teil der Dissertation befasst sich mit der Frage, wie Psycholog:innen in
Brasilien die psychosoziale Betreuung von Geflüchteten in diesem lateinamerikanischen Land
wahrnehmen. Teil II besteht aus drei verschiedenen Studien. Die erste Studie untersuchte, wie
Psycholog:innen das psychische Leiden und die Symptome ihrer geflüchteten Patient:innen
wahrnehmen. Sie liefert auch Hintergrund- und Kontextinformationen für die folgenden Teile, z.B.
über die Herkunftsländer von geflüchteten Patient:innen in Brasilien. Die Untersuchung ergab,
dass die häufigsten beschriebenen Zustände bei geflüchteten Patient:innen Angst- und
Depressionsstörungen und -symptome, Trauer und PTSD-Symptome waren. Die Ergebnisse
zeigten jedoch auch, dass die Verwendung von Manualen für die kategoriale Klassifizierung und
Diagnose psychischer Störungen unter Psycholog:innen in Brasilien umstritten ist, da
psychiatrische Diagnosekategorien oft als eine unzureichende Übersetzung der Erfahrungen einer
Person empfunden werden. Psycholog:innen tendierten dazu, das soziopolitische Leiden der
Patient:innen zu betonen und die Symptome der Patient:innen als normale Reaktionen auf deren
tiefgreifende Verluste und die anhaltende kontextuelle Instabilität zu konzeptualisieren. Die
Psycholog:innen diskutierten das Leiden von Geflüchteten insbesondere in Bezug auf vier Cluster:
die Stressoren nach der Migration, traumatische Erfahrungen, Flucht als Lebensbruch und die
aktuelle Situation im Herkunftsland.
Die zweite Studie von Teil II untersuchte die Perspektiven von psychologischen
Berater:innen auf MHS für Geflüchtete in Brasilien. Die Studie analysierte die allgemeinen
Erfahrungen, die positiven und negativen Aspekte sowie die hilfreichen Faktoren und notwendigen
Veränderungen zur Verbesserung der MHSR. Die Ergebnisse zeigten, dass die Berater:innen die
Erfahrung machten, in einem neuartigen, prekären und fremdenfeindlichen Kontext zu arbeiten,
was sie dazu veranlasste, über die klassische psychologische Arbeit hinauszugehen, praktische Hilfe
zu leisten und den Patient:innen teilweise sehr nahe zu kommen. Die Berater:innen berichteten
über einen Mangel an öffentlichen Strukturen, unzureichende Kompetenzen und eine hohe
Ermüdung und Burnout des Personals. Gleichzeitig schilderten sie positive Konsequenzen aus
ihrer Arbeit wie zum Beispiel, dass sie neue Perspektiven gewannen und davon profitierten, dass
sie die Widerstandsfähigkeit ihrer Patient:innen miterlebten. Was die hilfreichen Faktoren
anbelangt, so wiesen die Berater:innen darauf hin, wie wichtig es ist, dass die Berater:innen flexibel
und authentisch sind, eine hohe Frustrationsresistenz zeigen und gruppenbasierte Ansätze
anwenden. Die Berater:innen schlugen vor, dass sich die Bemühungen zur Verbesserung der
psychischen Gesundheit von Geflüchteten in Brasilien darauf konzentrieren sollten, eine sozialere
17
Zusammenfassung
und weniger individuumszentrierte Perspektive in der Psychologie einzunehmen,

Antidiskriminierungskampagnen und Strategien für die Integration von Geflüchteten zu
entwickeln und die Investitionen in die psychische Gesundheitsversorgung im Allgemeinen zu
erhöhen.
Die dritte Studie von Teil II ist eine Studie über die Erfahrungen von
Psychotherapeut:innen in der Psychotherapie für Geflüchtete in Brasilien. Unterstützende und
behindernde Elemente in der Psychotherapie mit geflüchteten Patient:innen in Brasilien wurden
auf acht verschiedenen Ebenen identifiziert: der/die Patient:in, der/die Therapeut:in, ihre
Beziehung, das Setting, der psychotherapeutische Ansatz, der Kontext der Patient:innen, der
Kontext der Therapeut:innen und der gesellschaftliche Kontext in Brasilien. Zu den hinderlichen
Elementen in der Therapie gehörten die fehlende Vorbereitung Brasiliens auf die Integration von
Geflüchteten, der Mangel an Sprach- und Kulturmittler:innen, das Misstrauen der Patient:innen
und das Gefühl der Therapeut:innen, unvorbereitet und hilflos zu sein und sich übermäßig zu
engagieren und zu involvieren. Unterstützende Elemente waren ein vertrauensvolles
therapeutisches Verhältnis, die kulturelle Bescheidenheit („cultural humility“) und strukturelle
Kompetenz („structural competency“) der Therapeut:innen, die gesellschaftliche Einbindung der
Patient:innen sowie die Arbeit mit Gruppen und Netzwerken. Diese Studie zeigte, dass angesichts
der enormen strukturellen Herausforderungen für das psychische Wohlbefinden von geflüchteten
Patient:innen die Flexibilität der Therapeut:innen und die Abhängigkeit von kollektiver Arbeit und
Unterstützungsnetzwerken von entscheidender Bedeutung ist.
In Teil III, dem Schlussteil dieser Dissertation, werden in einer integrativen Diskussion die
Ergebnisse der verschiedenen Studien dieser Dissertation zusammengefasst, verglichen und
einander gegenübergestellt bezüglich hilfreicher/positiver, ambivalenter und unterstützender/
negativer Faktoren in der MHSR. Diese synthetisierten Ergebnisse werden in der Folge in die
wissenschaftliche Literatur eingebettet und in Bezug auf diese diskutiert. Die Dissertation schließt
mit einer Betrachtung ihrer Limitationen und mit Vorschlägen für die zukünftige Forschung sowie
mit einer allgemeinen Schlussfolgerung.
18
Table of Contents
Acknowledgements ...................................................................................................................................... 4
Abstract ........................................................................................................................................................ 10
Table of Contents ....................................................................................................................................... 19
Abbreviations and Acronyms ................................................................................................................... 21
List of Tables .............................................................................................................................................. 22
List of Figures ............................................................................................................................................. 23
Introduction .............................................................................................................................................. 24
The Structure of the Dissertation .................................................................................................... 26
Chapter 1: The Dissertation and its Theoretical and Empirical Background ................................... 28
Some Thoughts on Terms Concerning Migration ........................................................................ 29
Refugees and Mental Health ............................................................................................................. 31
Mental Health Support for Refugees............................................................................................... 39
The Dissertation ................................................................................................................................. 48
Section I Mental Health Support for Refugees – Experiences of Professionals and Patients ...... 55
Chapter 2: A Qualitative Evidence Synthesis of Refugee Patients’ and Professionals’ Perspectives
on Mental Health Support. ....................................................................................................................... 56
Abstract................................................................................................................................................ 57
Introduction ........................................................................................................................................ 58
Method ................................................................................................................................................. 60
Results .................................................................................................................................................. 66
Discussion ........................................................................................................................................... 77
Conclusion and Recommendations for Practice and Future Research ...................................... 81
Chapter 3: Challenges to Qualitative Evidence Synthesis – Aiming for Diversity and Abstracting
Without Losing Meaning........................................................................................................................... 82
Abstract................................................................................................................................................ 83
Introduction ........................................................................................................................................ 84
Approaches and Use of QES in (Psychological) Research .......................................................... 87
Benefits and Challenges in Conducting QES ................................................................................ 89
Merging without Losing Meaning: Analysis of Primary Data...................................................... 96
Overall Conclusion and Outlook ...................................................................................................101
Section II Mental Health Support for Refugees in Brazil .................................................................103
Chapter 4: From a Synthesis of the Literature to Research in Brazil ...............................................104
19
Table of Contents
A Rationale for Investigating Experiences in Brazil ...................................................................105

Migrants and Refugees in Brazil .....................................................................................................107
Mental Healthcare in Brazil ............................................................................................................110
Context and Locations of the Interviews with Psychologists in Brazil ....................................113
Chapter 5: The Psychological Suffering of Refugee Patients in Brazil .............................................123
Introduction ......................................................................................................................................125
Method ...............................................................................................................................................127
Results and Discussion ....................................................................................................................129
Conclusion.........................................................................................................................................143
Chapter 6: Psychologists’ Perspectives on Providing Psychological Care for Refugees in
Brazil...........................................................................................................................................................144
Abstract..............................................................................................................................................145
Introduction ......................................................................................................................................146
Method ...............................................................................................................................................148
Results ................................................................................................................................................153
Discussion .........................................................................................................................................165
Conclusion and Implications ..........................................................................................................170
Chapter 7: Psychotherapy with Refugees – Supportive and Hindering Elements .........................172
Abstract..............................................................................................................................................173
Introduction ......................................................................................................................................174
Method ...............................................................................................................................................177
Results ................................................................................................................................................180
Discussion .........................................................................................................................................189
Conclusion.........................................................................................................................................194
Section III An Integrative Discussion .................................................................................................195
Chapter 8: Summarizing and Integrating the Results..........................................................................196
Summaries of the Results ................................................................................................................197
Specificities in the Results of the Studies ......................................................................................201
Commonalities across Studies ........................................................................................................206
Chapter 9: Limitations, Implications and an Overall Conclusion .....................................................233
Limitations of this Dissertation and Future Research ................................................................234
Practical Implications.......................................................................................................................240
Reflections on a Meta Level – Science and Psychotherapy as Cultural Products...................245
References................................................................................................................................................247
20
Abbreviations and Acronyms
APA American Psychological Association
AS Asylum-Seeker
CAPS Centros de Atenção Psicossocial [Brazilian psychosocial care centres]
CoO Country of Origin
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ICD-10 International Statistical Classification of Diseases and Related Health
Problems (10th revision)
IOM International Organisation for Migration
MDC Mental Disorder Classification
MHS Mental Health Support
MHSR Mental Health Support for Refugees
N North (Region in Brazil)
NGO Non-governmental Organisation
PSP Psycho-social professional
PTSD Posttraumatic Stress Disorder
QES Qualitative Evidence Synthesis
S South (Region in Brazil)
SE Southeast (Region in Brazil)
SUS Sistema Único de Saúde [Brazilian Unified Public Healthcare System]
UBS Unidades Básicas de Saúde [Brazilian basic units of healthcare]
UNHCR United Nations High Commissioner for Refugees
UNRWA United Nations Relief and Works Agency for Palestine Refugees in the
Near East
WEIRD Western, Educated, Industrialized, Rich and Democratic
WHO World Health Organisation
21
List of Tables
Table 1: Characteristics of the studies included in the synthesis ........................................................................ 64
Table 2: Characteristics of the participants in primary studies ......................................................................... 65
Table 3: Analytical clusters, allocated descriptive themes and studies that contributed to each............................ 67
Table 4: Databases, language of keywords and hits ......................................................................................... 92
Table 5: Participants’ characteristics .............................................................................................................117
Table 6: Patients’ countries of origin as reported by psychologists....................................................................129
Table 7: Categories of Suffering ....................................................................................................................133
Table 8: Disorders and Symptoms mentioned by psychologists organised according to the DSM-5 ...................136
Table 9: Characteristics of participating psychologists ....................................................................................150
Table 10: Participants endorsing themes related to the care experience ...........................................................154
Table 11: Participants endorsing themes related to barriers of the care experience ...........................................156
Table 12: Participants endorsing themes related to positive aspects of the care experience ................................158
Table 13: Participants endorsing themes related to facilitators in the care experience .......................................160
Table 14: Participants endorsing themes related to necessary changes to improve the care .................................164
Table 15: Characteristics of participating psychotherapists .............................................................................179
Table 16: Level of analysis, themes and frequency of occurrence of each theme .................................................181
22
List of Figures
Figure 1: Displaced people in numbers ........................................................................................................... 26
Figure 2: Risk and protective factors for migrant mental health (Rousseau & Frounfelker, 2019) .................. 35
Figure 3: The refugee journey. (Codrington et al., 2009) ................................................................................. 38
Figure 4: PRISMA flow diagram (adapted from Moher et al., 2010) ............................................................ 62
Figure 5: Analytical clusters grouped according to the research questions .......................................................... 67
Figure 6: Relations between analytical clusters ................................................................................................ 73
Figure 7: World map of primary studies’ origins ............................................................................................. 94
Figure 8: Map of countries of origin of asylum-seekers in Brazil in 2018 (CONARE, 2019).....................109
Figure 9: Map of participants’ places of work ...............................................................................................116
Figure 10: Places of work ............................................................................................................................119
Figure 11: Number of psychologists mentioning the respective country of origin of their patients .......................130
Figure 12: Map showing countries of origin of patients. .................................................................................130
Figure 13: Categories of Suffering ................................................................................................................132
Figure 14: Most frequently mentioned symptoms or states .............................................................................139
Figure 15: Themes relating to the five categories ............................................................................................153
Figure 16: The eight levels of analysis...........................................................................................................180
Figure 17: Connections of themes across levels ...............................................................................................189
Figure 18: An integrative view of positive, ambivalent and negative aspects of the MHSR .............................206
Figure 19: Patients’ post-migration context ..................................................................................................207
Figure 20: Transcending boundaries in the mental health support with refugee patients ..................................219
Figure 21: Three types of professional awareness ...........................................................................................224
23
Introduction
Je suis ici, ainda que não queiram não

Je suis ici, ainda que eu não queira mais
Je suis ici, agora.
Luedji Luna (2017)

Introduction
I remember the first time I wrote down the worldwide number of forcibly displaced people for
this thesis. It was at the beginning of 2018 and the statistic I obtained from the United Nations
Refugee Agency (UNHCR, 2018) showed that by the end of 2017 there had been 68.5 million
displaced people globally. As of the writing of this introductory part of my dissertation in the
summer of 2020, that number has risen to 80 million people (UNHCR, 2020).
This means that about 1 % of the world’s population is currently forcibly displaced, or one
in 97 people (UNHCR, 2020). Compared to the ratio of 1:159 in 2010 this shows a continues rise
in displaced people worldwide. Of these displaced people, 45,7 million are internally displaced
people, 26 million are recognised refugees, 4,2 million are asylum-seekers and 3,6 million are
Venezuelans who are displaced abroad (see Figure 1; UNCHR, 2019, 2020). The majority of the
displaced people in 2019 came from only five countries: Syria, Venezuela, Afghanistan, South
Sudan and Myanmar (UNHCR, 2019; 2020). Meanwhile, the countries that host the highest
number of refugees are Turkey, Colombia, Pakistan, Uganda, and Germany (UNHCR, 2020). After
arriving in host countries, refugees face various challenges – they have to deal with their past
experiences, which often involve human rights violations, extreme forms of violence, persecution,
fear for one’s life and witnessing the deaths of loved ones. They have to cope with material, social,
cultural and emotional losses and separation from their families. And finally, in host countries, they
are often confronted with xenophobia and hostile attitudes, facing discrimination, social exclusion,
precarious conditions as well as bureaucratic struggles (Hassan et al., 2016; Knipscheer & Kleber,
2006; Miller & Rasmussen, 2010; Rousseau, 2018). Even though many refugees do not develop any
form of mental health problem (Papadopoulos, 2007), these experiences and conditions are
considered to increase their vulnerability for psychological concerns (Beiser, 2009; Davidson et al.,
2008; Murray et al., 2010). Research has documented that a high prevalence of mental disorders
among refugees is related to the accumulative experience of stressors in the past and in the present;
in the country of origin and in the host societies (Davidson et al., 2008; Fazel et al, 2005; Hou et
al., 2020; Kartal & Kiropoulos, 2016; Lindert et al., 2009; Morgan et al., 2017; Silove et al., 2017;
Turrini et al., 2017). As forced displacement increases globally, there is a growing need to develop
mental healthcare services in host countries that appropriately meet the needs of refugees
(Karageorge et al. 2017).
This dissertation aims to foster our understanding of mental health support for refugees.
Particularly, its objective is to help researchers, mental health professionals and program developers
make use of insider knowledge by analysing how those who are involved in the mental healthcare
– namely patients and professionals – experience the therapeutic processes. In doing so, a specific
25
Introduction
focus is placed on the experience of professionals who provide mental healthcare to refugees in
Brazil.
Figure 1
Displaced people. Figure adapted from the report of the UNHCR (2020).
Displaced people (millions)

90
80
Displaced people in millions
70
60
50
40
30
20
10
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Year
Internally displaced people UNRWA & UNHCR refugees Asylum Seekers Venezuelans displaced abroad
The Structure of the Dissertation

The dissertation starts with Chapter 1, defining some key terms and introducing the
theoretical and empirical literature and scientific findings related to refugees and their mental
health. Specialised mental health support and therapeutic approaches for refugee such as
“Ethnopsychiatry”1 are also presented. The chapter concludes by outlining the need and potential
benefits of looking at the mental health support for refugees from an insiders’ perspective, namely
that of professionals and patients, and of integrating perspectives on the topic from non-Western
countries.
In what follows, the dissertation consists of three sections. Section one (Chapter 2 and 3)
assumes a meta-perspective. Chapter 2 is an investigation and synthesis of the existing qualitative
literature on the experiences and perspectives of professionals and refugee patients concerning
mental health support with refugees. It aims to foster our understanding on insiders’ perspective.
In doing this it will emphasis helpful aspects of the MHSR such as a trustful therapeutic
relationship, hindering elements, as the external instability of refugee patients, and ambivalent
1 Also referred to as Ethnopsychoanalysis.

26
Introduction
aspects, such as the question of the adequacy of trauma exposure. Chapter 3 describes the
methodology “qualitative evidence synthesis” that was used in more detail and discusses some of
the challenges encountered in the process.
The second section (Chapters 4-7) describes the fieldwork that we undertook in Brazil in
order to gain insights into the mental health support with refugees in this country. It opens with
Chapter 4, which gives some background information on mental healthcare and the situation of
refugees in Brazil. Chapter 5 looks at the psychological suffering that psychologists in Brazil
deemed most prominent in their refugee patients and described their countries of origins. It will
show that anxiety and depression were perceived to be the most common mental health problems
among refugee patients, but also that psychologists in Brazil experienced their patients suffering as
intertwined with their socio-political situation. The participants tended to criticise psychiatric
diagnostic manuals for neglecting this socio-political context and individualising the suffering of
patients. Chapter 6 focuses on psychologists’ experiences of providing “acolhimento psicológico”
(psychological care) for refugees in the Brazilian context. It will demonstrate that psychologists
perceived that a more integrative and social perspective in psychology, policies for refugee’
integration, anti-discrimination work, and investments in mental healthcare in general are essential
to better the mental health situation of refugees in Brazil. As the final part of the fieldwork, Chapter
7 analyses and discusses the perspectives of psychotherapists who work with refugee patients
clinically. It focuses on the supportive and hindering elements in the psychotherapy with refugee
patient. The chapter will illustrate that in light of the enormous structural challenges for the mental
well-being of refugee patients, therapists’ flexibility, cultural humility and structural competence as
well as the reliance on collective work and networks of support becomes crucial.
The third section (Chapter 8 and 9) summarises, compares and contrasts the findings of
the previous chapters. It discusses the results in an integrative manner while embedding them in
the scientific literature. The final chapter of this dissertation, Chapter 9, shows some practical
implications, provides an overall conclusion and makes suggestions for future research while
emphasising the need for a meta-perspective and critical reflection on current psychological
scientific practices.
27
Chapter 1
The Dissertation and its Theoretical and
Empirical Background
Chapter 1 Theoretical and Empirical Background
Some Thoughts on Terms Concerning Migration

Displaced people are considered a subgroup of migrants. There is no universally accepted
definition for the term migrant. The International Organisation for Migration (IOM, 2019, p. 132)
describes the term as
an umbrella term, not defined under international law, reflecting the common lay understanding of a person
who moves away from his or her place of usual residence, whether within a country or across an international
border, temporarily or permanently, and for a variety of reasons. The term includes a number of well-defined
legal categories of people, such as migrant workers; persons whose particular types of movements are legally-
defined, such as smuggled migrants; as well as those whose status or means of movement are not specifically
defined under international law, such as international students.
However, displaced people differ in such from voluntary migrants, as for instance expatriates
or international students, that their migration was forced by external factors such as war and armed
conflicts, violence and persecution. Voluntary migrants usually planned their migration in advance
and, in most cases, a return to their country of origin is possible. In contrast to this, for forcibly
displaced people or involuntary migrants, socio-political conditions render such a return unattainable, for
an extended period of time (Kizilhan, 2018; Martins-Borges, 2019). However, in reality, the
distinction between voluntary and forced migrants or displaced people is often not clearly cut
(Scalettaris, 2007).
Displaced people include officially recognised refugees, asylum-seekers who are still waiting for
their asylum claims to be processed and internally displaced people, according to the UN (UNHCR,
2020). The term refugee holds various juristic, ethical and social science definitions which differ
according to the institutions and countries which use them and their purposes (Bógus & Rodrigues,
2011; Zolberg et al., 1989). In ordinary usage the term describes someone who is in flight, searching
protection in a different country, as circumstances in the country of origin are intolerable
(Goodwin-Gill & McAdam, 2007). From a legal status perspective, differentiations are being made
between asylum-seekers, whose applications for asylum in a host country have not yet been accepted,
and refugees, who have officially been recognised as entitled to protection. The article 1A of the
“Convention Relating to the Status of Refugees” in 1951 established an international legal basis for
the protection of people of this category (Malkki, 1995; Scalettaris, 2007) and defines a refugee as
“someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted
for reasons of race, religion, nationality, membership of a particular social group, or political opinion” (UNHCR,
29
2010). The Cartagena Declaration on Refugees (1984) develops a broader definition of refugee –
according to the Declaration (Goodwin-Gill & McAdam, 2007, p. 624)
the definition or concept of a refugee to be recommended for use in the region is one which, in addition to
containing the elements of the 1951 Convention and the 1967 Protocol, includes among refugees persons
who have fled their country because their lives, safety or freedom have been threatened by generalized violence,
foreign aggression, internal conflicts, massive violation of human rights or other circumstances which have
seriously disturbed public order.
Meanwhile, it has been criticised, by social scientists in particular, that most international
definitions of the term refugee do not live up to the complex forms and causes of global movements
of flight and displacement (Nuscheler, 1995). The UN definition for instance, does not allow
displaced people who are fleeing from natural disasters or humanitarian crisis do be categorised as
refugees (Glynn, 2012). For this reason, Venezuelans in Figure 1 form an extra category instead of
being included within the UNHCR refugee statistics. Most of the Venezuelans who leave their
country are trying to escape hunger, violence and misery, but not war or persecution (Oliveira et
al., 2019). Most Haitians who left Haiti after the earthquake in 2010, which destroyed large parts
of the country’s economy and the livelihood of many people, also do not conform to the UN’s
definition of a refugee. In some countries, such as Brazil, Haitians and Venezuelans are instead
provided with humanitarian visa (Véran et al., 2014).
Applying the legal and political terms to the academic field seems difficult (Scalettaris,
2007), even though relevant, as the legal status of a person in a host or resettlement country can
greatly influence the feelings of security and thus the well-being of this person (e.g. Kronsteiner,
2003; Momartin et al., 2006). However, it is important to remember that becoming a refugee is not
a psychological, but exclusively a legal and socio-political phenomenon. Any ordinary individual
becomes a refugee the moment that she is forced to leave her home due to socio/political
circumstances and seek refuge in a host country (Papadopoulos, 2007).
Instead of following a legal definition of the term refugee, this dissertation will use a more
comprehensive understanding “on a sociological basis, that is, according to criteria grounded in observable social
realities, independent of any determination by official bodies or by the refugee’s own claims” (Zolberg, 1989, p.
18). In other words, individuals are considered refugees here, if they are “forced abroad in order to
survive, either because their own state is the cause of their predicament or because it is unable to meet […] basic
requirements”. (Zollberg, 1989, p. 48). Thus, in what follows, I will employ the term refugee capturing
all externally displaced people (excluding internally displaced people) and not differentiate between
people’s official legal status. Certainly, people with flight experiences are very heterogenous in
terms of background, experiences and future prospects (Bógus & Rodrigues, 2011; Bozorgmehr et
30
al., 2016). In such there is no singular experience of “being a refugee” (Scalettaris, 2007, p. 40).
However, grouping together these individuals under the term refugees is based on the assumption
that they find themselves in a comparable predicament that is distinct from that of the general
population (Kirmayer, 2002). A distinction between asylum-seekers who are still waiting for their
asylum claims to be processed and refugees who have a secured legal status in a host country will
only be made when necessary, such as when the legal status of a person becomes relevant for her
mental health2 (Momartin et al., 2006).
Refugees and Mental Health

Researchers have increasingly started to pay attention to the psycho-social and health
consequences of flight, notably since the 1990s (Bhugra et al., 2014; Gavranidou & Abdallah-
Steinkopff, 2007). Many studies have found higher prevalence rates of mental disorders3 in refugees
in comparison to the general population of host countries. The following paragraph describes some
of the findings from studies investigating the mental health and illness and introduces the most
important factors influencing the mental health of refugees. While the aim of this section is to
introduce the strains and struggles of immigrants and refugees, this should not be viewed as a
contribution to a pathologisation of migrants or a medicalisation of their problems (Bracken et al.,
1995). In contrast, discussing the enormous psychological and socio-political challenges and
burdens of the migration and flight processes underscores the resources and profound resilience
of migrants who cope with these challenges and manage to live in new countries (Papadopoulos,
2007; Sieben & Straub, 2018). Therefore, this dissertation is based on the assumption explicated
by Punamäki (2000) and others, that the striving for individual healing does not oppose socio-
political struggles for justice and human rights.
Prevalence of mental disorder among refugees

Prevalence rates of mental health disorders among refugees are inconsistent, but tend to be
high. Especially elevated rates of depression and anxiety have been described in refugees (Lindert
2 “Mental Health” is understood in this thesis as outlined by the World Health Organisation (WHO) as: “a state of well-
being in which every individual realizes his or her own potential can cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to her or his community” (WHO, 2019)
3 Throughout this dissertation, the denomination of terms of mental illnesses (e.g. “depressive disorder”) is in
accordance with the respective reference from which the term was taken. Furthermore, the expression “psychological
suffering” is used to allow for the inclusion of a range of experiences and mental states that are considered troubling,
confusing or not perceived to be healthy by the people concerned. This expression was chosen to capture a wider
scope of problems than the designation “mental disorder” alone would characterise.
31
et al., 2009; Turrini et al., 2017). For instance, in a systematic review, Lindert et al (2009) found
combined prevalence rates among refugees of 40 % for anxiety disorder, 44% for depression and
36 % for post-traumatic stress disorder (PTSD). The high prevalence of PTSD among refugees
has been particularly emphasised in the literature. The rates vary greatly among studies, from at
least at 16 % (Bozorgmehr et al., 2016) to up to 40 % (Gäbel et al., 2006). Fazel et al. (2005) reported
that it is 10 times more likely for a refugee to develop PTSD than for an age-matched person from the
general population in a host country. These high rates of PTSD have been found independently of a
person’s country and culture of origin (Nickerson et al., 2011).
Various factors can explain the augmented vulnerability in refugees to develop some sort of
mental disorder – the process of migration and culture shock, the exposure to pre-flight trauma and
hardship during flight and the post-migration situation in host countries. These factors will be described
in more detail in what follows.
Migration, culture and mental health

International migration, that is the moving away of a person “from his or her place of usual
residence” (IOM, 2019), is a process that carries a high potential to influence and change an
individual. Immigrating implies a rupture, to greater of lesser extent depending on the
circumstances, of a person with her origins. Immigrants do not only change their place of residency,
but also migrate from a culture of origin to a new culture.
The definition of culture differs considerably among different academic disciplines (Martins-
Borges, 2013). In this dissertation culture is understood as “the dynamic and ever-changing contents of
those relations and interactions, webs of significance that are shaped and reshaped in social life and in relation to
structures of power.” (Eastmond, 2000, p. 68) Thus, culture is not perceived as something fixed, but
rather as always moving and as created and changed by human beings in a daily and procedural
manner. In a way this understanding relates to ethnological perspectives on culture, which tend to
emphasise its performative dimension. In such a view, culture is made by the actors in social
relationships (Basu & Gies-Powroznik, 2018). “Culture is social (and often public) because such systems [of
semiotic practices that both facilitate and constrain human meaning making] must be shared; there is no culture of
one.” (Kirmayer & Gone, 2010, p. 80). Culture is the social world we are embedded in from birth,
providing us with resources on the one hand, and constraints on the other. Culture is historically
transmitted as generations are socialised into using the systems of semiotic practises, while
modification and new innovations are constantly made to adapt to changing circumstances
(Kirmayer & Gone, 2010). Culture serves people as a system for organisation, guides and orientates
action, gives meaning and safety and, from the perspective of Ethnopsychiatry, thereby, structures
the internal and external world of an individual (Kronsteiner, 2003; Martins-Borges, 2013).
32
Therefore, Tobie Nathan refers to culture as a “mental map” that fulfils the function of guiding its
individual members and of helping them to avoid fear and encounter, process and confront
complexity in life (Nathan, 2001; Martins-Borges, 2013, 2019; Martins-Borges et al., 2019). A
member of a cultural group refers to and utilizes this mental map or cultural frame of reference to know
and understand the correct or ideal behaviour and the appropriate beliefs, attitudes, practises and
preferences in a culture (Guzder, 2014; Ogbu, 1993). Similar to the concept of mental maps, the
idea of cultural scripts refers to “organised units of knowledge that encode and propagate meanings and practices”
(Ryder et al., 2011, p. 961). According to this idea, every person can access a number of diverse
cultural scripts which can be primed by cultural cues (Hong & Chiu, 2001). The scripts become
observable once they are enacted as behaviour. They form expectancies and assumptions about the
thoughts and behaviour of others (Chiu et al., 2010). For instance, shared cultural contexts lead
members to have similar scripts available concerning the feeling and the expression of emotions
(Ryder et al., 2011). In the case of unusual and preoccupying experiences people also make of use
of their cultural scripts in order to make sense of the unusual or pathological (Ryder et al., 2011).
When migrants and refugees leave their country of origin, they often leave behind aspects
of their culture and find themselves confronted with new cultural scripts or cultural frames of references.
In the conceptualisation of Ethnopsychiatry, this can disrupt the functionality of the scripts or
mental map which guided the individual up until that point. Thus, the migration can shatter the
communication between the inner and outer world of an individual which in turn can lead to an
increased vulnerability of the individual to develop mental health problems (Martins-Borges, 2013).
People often experience a decisive break in their lives or even an existential crisis as a result of the
migration (Kronsteiner, 2003). The concept of a migration crisis and the associated concept of
culture shock and its consequences for the human psyche have been described in the scientific
literature, particularly since the publications of the Canadian anthropologist Kalervo Oberg (Oberg,
1954; 2006) in the 1950s, and the Argentinian psychoanalyst César A. Garza-Guerrero (1974) in
the 1970s (Kronsteiner, 2003; Ward et al., 2005). Garza-Guerrero conceived culture shock as
consisting of two major aspects. First, a process of grief due to a loss of the culture of origin and
second, changes in one’s identity caused by the interactions with a new culture (Garza-Guerrero,
1974). Oberg’s model suggests four phases: Euphoria (everything is new and exciting, expectations
are high), culture shock (problems appear, disillusionment, loneliness), recovery (accepting
differences, positives and negatives become more balanced out) and adaptation (realistic
acceptance). However, the concept of culture shock has been criticised because firstly, it conveys
an overly negative image of migration. Secondly, it suggests that the upsetting crisis is a necessary
condition for adaptation. Thirdly, the concept is based on a rather static and homogenous
understanding of culture. Finally, the idea does not reflect upon the normative character of the
33
term adaptation (Sieben & Straub, 2018)4. Meanwhile, there is consensus that migration is a complex
and heterogenous phenomenon. Every individual goes through (and not always in a linear fashion)
a number of stages of adjustment, and response to many diverse stressors during the preparation,
the actual migration and in the postmigration situation (Bhugra, 2004).
There is also widespread agreement that immigrants often have to leave behind many
elements that were essential pillars of their identity until the moment of migration, such as their
home, habits, relationships as well as their social and professional status (Martins-Borges, 2013).
As in Irena Brežnás (2014, p. 18, p. 23) novel “Die undankbare Fremde” 5 the main character, a
Slovenian young woman who came to Switzerland after the violent ending of the Prague Spring,
states:
Für mich war mein Land verspielte Muttersprache gewesen, Lachen mit meinen Freundinnen,
selbstverständliches Zugehörigkeit, ein warmer Strom, der mich getragen hatte. Ich hatte Kiemen gehabt,
und auf einmal wurde ich ans Ufer geworfen, hörte das Wachsen der Lungen, und jeder Atemzug
schmerzte […] Dankbar sollte ich sein, hier leben zu dürfen. Und stets pünktlich. Wem und worfür sollte
ich pünktlich dankbar sein, dass es mir in der besseren Welt so schlecht ging? Zuhause ist dort, wo man
motzen darf, und ich hatte kein Zuhause.6
Transformative processes affecting migrants’ self-concepts and identities, as well as the

question of inclusion of migrants in the new country, can be a cause of distress and dysfunction in
some people (Bhugra & Minas, 2007), a weakening of the social localisation of the individual
(Martins-Borges & Pocreau, 2009b) and an erosion of her identity (Bhugra & Minas, 2007;
Kizilhan, 2018). Often, the coping strategies to deal with problems and concerns which immigrants
have learned and used in their country of origin do not work in a new country anymore, since their
resource networks are absent (Kizilhan, 2018). Furthermore, mental blockades, that are difficult to
dissolve, can develop through the loss of a cultural frame of reference, through discrimination
experiences and difficulties in relating to the host country’s majority population, as well as through
the dependencies on bureaucracies and institutions of the host country (Martins-Borges & Pocreau,
2009b). The latter often place constraints on the “Handlungsfähigkeit” of an individual, i.e. the
4 For a further discussion regarding these criticisms please see Sieben and Straub (2018).
5“The ungrateful stranger” [I translated the title of the book which was written in German and does not have an
English translation, yet. However, it is available in several other languages as for instance French: "L`ingrate venue
d`ailleurs" or Slovakian: "Nevdačná cudzin(k)a, (Aspekt, Bratislava, 2014)]
6 “For me, my country had been a playful mother tongue, laughter with my friends, self-evident, natural belonging, a
warm stream that had carried me. I had had gills, and suddenly I was thrown to the shore, heard my lungs grow, and
every breath was painful [...] I should be grateful to be allowed to live here. And always on time. To whom and for
what should I be so punctually grateful, since I was so miserable in the better world? Home is where you can complain,
and I had no home.” [As in the following extracts taken from the book, the translation is my own]
34
socially mediated control over one's own life and living conditions (Holzkamp, 1983, p. 239).
Additionally, problems in communcation come into play, as immigrants often speak a different
language than the majority population in the new country and so constantly face language barriers
(Kizilihan, 2018). Finally, in their daily lives in the new country many immigrants are confronted
with socio-economic hardship, racism, xenophobia and discrimination relating for instance to
ethnicity, skin colour or religion (Basu & Gies-Powroznik, 2018; Rousseau & Frounfelker, 2019).
Experiencing racism and discrimination has been associated with worse mental health outcomes
(Ziersch et al., 2018). Figure 2 below shows a summary by Rousseau and Frounfelker (2019) of the
primary (premigration) and secondary (postmigration) stressors for migrants alongside two time
axes. Time axis one displays the migration journey from living in the country of origin to
resettlement or detention. Time axis two adds the stages of development of person from birth to
old age. The figure also shows protective factors as moderators such as family support, access to
services and employment. In their review of the literature, Rousseau and Frounfelker (2019, p. 3)
explain how the stressors can increase the vulnerability of migrants to develop mental disorders
such as PTSD, anxiety, depression and other severe mental illness.
Figure 2
Risk and protective factors for migrant mental health (Rousseau & Frounfelker, 2019, p. 3)
To put it briefly, the migration experience with all that it involves – leaving behind elements
of one’s culture and identity, being confronted with new cultural scripts or frames of references,
familiarising oneself with a new country, facing language barriers, bureaucratic struggles, socio-
35
economic hardship and discrimination – can have profound impacts on the mental health of
immigrants (Garza-Guerrero, 1974; Kronsteiner, 2003; Martins-Borges, 2013; Oberg, 2006; Ward
et al., 2005). It has to be stressed here, however, that migration processes can have positive
psychological consequences too (Silva-Ferreira, 2019; Kizilhan, 2018). For instance, through the
dealing with many stressful situations migrants can develop special coping strategies (Kizilhan,
2018). Some studies have found that migrants sometimes actually experience higher well-being than
host nationals, particularly related to feelings of social contribution and actualisation, personal
growth and purpose in life (Bobowik et al., 2015). Posititve personal changes can also occur
regarding a growing respect for differences and greater intercultural knowledge, as well as increases
in autonomy (Silva-Ferreira, 2019; Silva-Ferreira et al., 2019). Particularly for involuntary migrants,
immigration can provide the possibilty, if inclusion strucutres in the new country are in place, for
a personal continuity and a resuming of one’s life projects which were rendered impossible in the
country of origin due to wars and conflicts, violence, and persecution.
Impact of flight
The complexity of risk factors for a person’s mental health becomes even more
pronounced in the case of refugees. In addition to the experiences of culture shock, socio-
economic hardship, discrimination, changes in identity, loss of a cultural frame of reference, as well
as loss of the social embeddedness in the country of origin, refugees face specific struggles that are
related to their experiences in countries of origin, during forced displacement and to their legal
status.
First of all, many refugees have to cope with exposure to war, genocides, famines, human
rights violations, imprisonment, torture and flight (Kronsteiner, 2003; Ward et al., 2005). These
experiences are distinct for each refugee and depend, inter alia, on the socio-political situation in
their country of origin, manner and route of their flight, their membership to a specific ethnic,
linguistic or religious minority, their gender, and their financial situation. Exposure to trauma does
not always lead to mental health problems (Bisson et al., 2015; Martins-Borges, 2019), clinical
symptoms or lack of coping resources (Punamäki, 2000). Nevertheless, robust associations have
been made between pre-flight trauma and the mental health of refugees (Davidson et al., 2008;
Silove et al., 1997). For instance, refugees and survivors of human rights abuses show higher rates
of PTSD than the general population (Campbell & Steel, 2015; Fazel et al., 2005). Eisenbruch
introduced the concept of cultural bereavement as an alternative to PTSD (Bhugra & Becker, 2005;
Eisenbruch, 1991) to describe the complexity of experiences of loss and suffering in displaced
people. He defined cultural bereavement (Eisenbruch, 1991, p. 675) as
36
the experience of the uprooted person – or group – resulting from loss of social structures, cultural values
and self-identity: the person – or group – continues to live in the past, is visited by supernatural forces from
the past while asleep or awake, suffers feelings of guilt over abandoning culture and homeland, feels pain if
memories of the past begin to fade, but finds constant images of the past (including traumatic images)
intruding into daily life, yearns to complete obligations to the dead arid, feels stricken by anxieties, morbid
thoughts, and anger that mar the ability to get on with daily life. [Cultural bereavement] is not of itself a
disease but an understandable response to the catastrophic loss of social structure and culture.
In addition to the traumas they experienced themselves, many refugees are in a state of
permanent worry and preoccupation about their country of origin and those who are still living
there – relatives, friends and colleagues. Hearing news about political occurrences in their country
of origin is unsettling and the literature shows that refugees from countries whose conflicts are still
unresolved have worse mental health outcomes (Porter & Haslam, 2005). Furthermore, survivor guilt
has been reported as a common phenomenon among refugees, affecting those who had the
opportunity to escape violence and seek refuge in a different place while having to leave behind
loved ones (Eisenbruch, 1991; Martins-Borges, 2013).
Finally, an important factor is the question if the departure from one’s home and the arrival
in a new country was voluntary. This question is relevant as perception or feeling of having control
over one’s destiny tends to increase the more freely chosen the migration was (Kizilhan, 2018). For
many refugees, flight to a new country is the only option to survive. Most do not choose the host
country according to personal preferences, as for instance exchange students might, but according
to practicalities. Reasons include having family that already resettled in the country, the route to
the country being relatively manageable, or certain asylum procedures in the country being
beneficial for their particular situation (Barsky, 2017; McAuliffe & Jayasuriya, 2016). Sometimes
the choice is not even a real choice (McAuliffe & Jayasuriya, 2016), but purely random or dependant
on resettlement plans of countries or international organisations, and so completely out of the
control of the displaced person. This is exemplified by the film The Good Lie7 in which Sudanese
refugees are relocated to the United States without having so much as knowledge about the country
or its geographical location. Thus, refugees are often exposed to circumstances beyond their
control concerning their flight and arrival in a new country. The absence of a feeling of control
over one’s future and life, or in effect the lack of power, is a key element behind negative stress
(Kizilhan, 2018; McCubbin, 2009; Ogden, 2012).
7 Written by Margaret Nagle and directed by Philippe Falardeau (2014)

37
Mental health and the post-migration situation

Research on refugee mental health has shifted recently from a focus on premigration
trauma towards a focus on post-migration stressors (Davidson et al., 2008; Silove et al., 2017) and
on how these stressors might interplay with and exacerbate previous traumas and suffering
(Cleveland et al., 2014). Figure 3 displays the factors impacting the mental health of refugees in a
version adapted from the Australian Adolescent Family Therapy and Mediation Service (Codrington
et al., 2009, p. 130). Factors are shown alongside the “refugee journey” starting with the country
of origin in the inner circle, the flight in the middle, and the post-migration situation in the outer
circle.
Figure 3
The refugee journey. Adapted from Codrington et al., 2009, p. 130
Post-migration stressors for refugees in the post-migration situation include, in addition to

the stressors experienced by other migrants, feelings of social isolation due to family separation
(Kizilhan, 2018; Miller & Rasmussen, 2010) and experiences of discrimination and xenophobia, in
particular related to their refugee status (Beiser & Hou, 2016; Davidson, 2008). Especially while a
displaced person is still seeking asylum and has not received an official legal status yet, tedious
asylum application procedures, insecurity about one’s future and status residency, as well as
prolonged detention increase the feeling of lack of control and impact the mental health of that
person (Comtesse & Rosner, 2019; Davidson et al., 2008; Kizilhan, 2018). Studies have shown for
38
instance that the longer the duration of the asylum procedures are, the lower the quality of life of
asylum-seekers is (Laban et al., 2008). Also, not having a work permit has been associated with the
development of mental health problems such as anxiety and PTSD (Silove et al., 1997). Further
stressors in the post-migration situation for refugees are the often limited access to services
including healthcare, financial troubles and unemployment (Bogic et al., 2012; Gerritsen et al., 2006;
Silove et al., 2017). Unemployment, for instance, has been identified as a predictor of anxiety,
PTSD and depression (Carlsson et al., 2006; Beiser & Hou, 2001; Lavik et al., 1996).
Mental Health Support for Refugees

This subsection briefly introduces some definitions of key terms related to mental health
support, explains why the mental health support for refugees (MHSR) is something that requires
distinct attention, and finally outlines some of the research that has already been conducted in the
area of MHSR.
Psychotherapy, psychological care and counselling as types of mental health

support
The umbrella term Mental Health Support is used in this dissertation to refer to all types of
services that have been developed and are available to people who suffer from mental health
problems, including in particular psychotherapeutic and counselling services. Psychotherapy,
psychological care and counselling are overlapping, but somewhat distinct ways to approach mental
healthcare. Psychotherapy is, according to Wampold and Imel (2015, p. 37) understood as
a primarily interpersonal treatment that is a) based on psychological priniciples b) involves a trained

therapist and a client who is seeking help for a mental disorder, problem, or complaint c) is intended by the
therapist to be remedial for the client’s disorder, problem, or complaint ; and d) is adapted or individualised
for the particular client and his or her disorder, problem or complaint.
Distinct from some of the various methods of psychological healing that exist, psychotherapies
make use of explicit talk about the patient’s emotions, feelings, thoughts, and relationships in order
to bring about change (Kirmayer, 2007). Counselling as well as psychological care can have quite diverse
meanings and definitions and the terms are sometimes used interchangeably with each other and
with psychotherapy (McLeod, 2003). In this thesis, the term “psychological care” is used to refer
to the Brazilian concept of “acolhimento psicológico”. “Acolhimento psicológico” is an intervention strategy
in Brazilian mental healthcare that involves the reception of people with psychological concerns
and the provision of a space for listening to and bonding with patients, and accompanying them in
39
the process of improving their mental health and well-being (Ministério da Saúde, 2010). In that, it
is very close to the concept of counselling. However, the term counselling is a protected
professional label that requires its proper licensure in some other countries, particularly in North
America. The initiative “20/20:A Vision for the Future of Counseling” (Kaplan et al., 2014, p. 370)
involving 33 counselling organisations developed the following definition for professional
counselling, using a Delphi process:
Counseling involves professional relationships designed to assist individuals, families and groups toward
mental health, wellness, educational and career goals.
As there is no universal, international agreement upon the difference between psychological

care, counselling and psychotherapy, important for this dissertation is that, in the literature there is
a prevailing description of psychotherapeutic work as focused on remedying mental health
disorders, as “clinical” work that is often long-term and very much focused on the intrapsychic
level of an individual (Kirmayer, 2007; Wampold & Imel, 2015). In contrast, counselling or
psychological care are often perceived as oriented toward well-being of individuals without
necessarily being “clinical” work, thus attending to the needs of people who may not suffer from
a mental disorder, but face more everyday concerns, worries and problems. Counselling and
psychological care often involve psychotherapeutic aspects and aspects of social work, and can be
as short as one session. These concepts are focused on the individual, but also very much on his
social context (Kaplan et al., 2014).
What distinguishes MHSR from other forms of mental health support?

The increased vulnerability of refugees to mental health issues makes the provision of
mental healthcare services for this population a necessity. However, as elaborated above, the
experiences of refugees and their relation to mental health are quite unique and clearly embedded
in a socio-political context. This turns the mental health support of refugees (MHSR) into
something that needs particular attention (Bustamante et al., 2016).
First of all, refugees face specific barriers to the access of mental healthcare services. These
barriers include not having a public health insurance, suffering from a precarious economic
situation and the lack of financial means to pay for mental healthcare privately or for transport
(Asgary & Segar, 2011; Franks et al., 2007), and not being familiar and not having access to
information about the healthcare system and its services (Codrington et al., 2011; Sandhu et al.,
2013). Often, there are also different understandings of mental health and mental health problems,
as well as a lack of (culturally) appropriate services which hinders people in seeking out help (Asgary
& Segar, 2011; Donnelly et al., 2011; Franks et al., 2007). Furthermore, many refugees find
40
themselves in a post-migration context in which their basic needs are not met, which limits the
time and energy they are capable of dedicating to the search for mental healthcare services. A deep
mistrust of authorities and public services in many refugees also serves as a barrier to accessing
mental healthcare (Asgary & Segar, 2011; Franks et al., 2007). The language differences and the
lack of languages competencies among staff or of interpreters in public healthcare of the host
countries often represent further difficulties (Bustamante et al., 2016; Franks et al., 2007; Rousseau
& Frounfelker, 2019). Finally, stigma of mental health problems and psychotherapy is still widely
spread globally and hinders many people in general to seek out help (Franks et al., 2007; Silove et
al., 2017).
Secondly, when refugees do manage to access services, they, as well as their mental health
professionals, are confronted with a number of specific struggles. The language barrier, for
instance, not only limits access, it also complicates the therapeutic process – the financial costs of
interpretations or cultural brokers are unclearly covered in many countries (Mewes et al., 2016;
Yick & Daines, 2017) and sometimes psychotherapists end up partially financing these themselves.
In many contexts there is a general lack of qualified interpreters (Ku & Flores, 2005). Translation
cannot be provided by anyone (particularly not by the children of patients, which is all too often
the case, see Rousseau and Frounfelker, 2019). People who translate in psychotherapeutic settings
have to be trained and prepared as they will be likely exposed to many traumatic stories, and are at
risk to develop vicarious traumatisation. Their presence influences the dynamic in the
psychotherapeutic space in both negative and positive ways (Gartley & Due, 2017; Kluge &
Kassim, 2006; Leanza et al., 2015; Miller et al., 2005; Yick & Daines, 2017). Furthermore, there are
many professional challenges for mental healthcare professionals when working with refugees. For
instance, professionals have to be aware of the fact that many refugees do not have a “safe home”
to return to after a session, but continue in high instability (Brunnet et al., 2018; Carrasco García,
2010; Davidson et al., 2008; Knobloch, 2015; Momartin et al., 2006). Their refugee patients also
mostly have a different cultural background than their own. This makes cultural competence or
cultural sensibility an important skill for these professionals. Culturally inappropriate interventions
can contribute to the suffering of refugee patients (Kirmayer et al., 2014).
41
Culture and complexity in the therapeutic space

There is an uncertainty concerning the universal applicability of Western8 treatment models
and approaches (Kirmayer & Pedersen, 2014; Patel, 2003a). Many authors have stated that
psychotherapy with people from non-Western countries and cultures cannot simply follow
Western ideas and approaches (Kizilhan, 2006; Machleidt, 2006). One specific point of concern are
psychiatric diagnostic strategies and manuals, as well as conceptualisations of psychopathologies in
a more general sense (Gone & Kirmayer, 2010; Kirmayer & Pedersen, 2014). The appropriateness
of the global and universal use of psychiatric diagnostic categories following the common Western
diagnostic manuals ICD-109 and DSM-510 has been questioned multiple times (Haasen et al., 2005;
Kronsteiner, 2003; Miller et al., 2009; Summerfield, 1999). Sometimes symptoms of patients from
non-Western backgrounds simply do not fit the Western psychiatric diagnostic categories and the
application of the Western classification systems can lead to miss-interpretations of disorder or
illness (Kizilhan, 2006; Wohlfart & Zaumseil, 2006).
An often-cited example is the Western diagnostic category “Post-traumatic stress disorder”
(PTSD), which has reached non-Western realities globally (Argenti-Pillen, 2000). It developed out
of the “unusual political alliance” between psychiatrists and activists from the “Vietnam Veterans
Against the War” in the USA in the late 1960s (Gone & Kirmayer, 2010, p. 33). The context of this
development was a very specific one; criteria for the diagnosis were derived from adult male
soldiers who had experienced war trauma; but the concept became “universal” and reified when it
was officially recognised by the American psychiatric establishment (Courtois, 2004; Gone &
Kirmayer, 2010). It was further shaped by research on child abuse, domestic violence and rape
(Friedman et al., 2007). A number of scholars have uttered the need for caution about the export,
transference and application of the PTSD concept and associated treatment approaches to other
contexts (e.g. Becker, 1997, 2014; Bracken et al., 1995; Summerfield, 1996). Reasons for this caution
include11 particularly that it describes the reactions to circumscribed traumatic events, to prototypes
of combat, rape and disaster (Herman, 1992). For many people who suffer from traumatic
symptoms, especially for refugees or survivors of prolonged traumatic exposure, the concept does
not translate the complexity of their suffering and psychic realities (Bracken et al., 1995; Courtois,
2004). Professionals applying the diagnosis PTSD and using associated treatments, may fall into
8 The term West(ern) is used in this dissertation to refer to North American and Western European countries., as well
as to Australia and New Zealand.
9 International Statistical Classification of Diseases and Related Health Problems (10th revision)
10 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
11 Apart from the fact that PTSD, as all psychiatric diagnostic categories, is based on specific (cultural) assumptions
for instance about ethics, time, memory and forgetting (see e.g. Argenti-Pillen, 2000; Young, 1997).
42
the pitfall of not taking into consideration the context of the person who is showing traumatic
symptoms, but of locating the impacts of trauma instead purely in the individual and in medical
terms (Becker, 1997; Bracken et al., 1995).
Since the beginning of the 20th century, a number of different theories, perspectives and
approaches to treatment have been developed in various countries to account for cultural
differences in mental healthcare. The history of cross-, trans- or simply cultural psychiatry and
psychology is very complex and intertwined with the history of colonialism and politics of power
(Kirmayer, 2017). Despite diverse efforts to develop perspectives, treatments and interventions to
provide alternatives to Western universalistic ideas on psychopathology, psychiatric and
psychotherapeutic treatment, there is a persevering legacy of colonialism in the field that becomes
visible in de-contextualised perspectives of mental health problems, “romance with exoticism”, and the
tendency to “reify and essentialize culture as individual traits” (Kirmayer, 2017, p.13).
In what follows a short introduction to Ethnopsychiatry, which is a set of psychological
perspectives taking culture and cultural differences into consideration, will be given, as these
perspectives are of special relevance for the second section of this dissertation. There are various
forms of Ethnopsychiatry (Kirmayer, 2017). The groundworks for these perspectives have been
developed in France using psychoanalytic methods to study people cross-culturally (Devereux,
1978; Kronsteiner, 2003; Martins-Borges & Pocreau, 2009a; Martins-Borges et al., 2019; Nathan,
2001, 2006). The perspectives were strongly influenced by George Devereux and are based on the
encounter and complementarism of psychoanalysis and anthropology (Martins-Borges & Pocreau,
2009a; Martins-Borges et al., 2019; Sturm et al., 2010, 2011). Sturm et al. (2011, p. 205) explain:
French ethnopsychoanalysis combine a psychoanalytic perspective on the conscious and unconscious

dimensions of subjectivity with an exploration of the social and symbolic contexts referred to by the patient.
Ethnopsychiatry serves as a number of psychological approaches to look at human beings,

their individual psychological functions and the modalities of their interaction on the basis of their
multiple connections to languages and places, to goddesses, ancestors and behaviours (Nathan,
2006). In the therapy with migrants, Ethnopsychiatry uses multilayer approaches to deal with the
conditions and consequences of the migration for the subject and her social context (Kirmayer,
2017). From this set of perspectives psychological, social and cultural dimensions are equally
important for any transcultural and interpersonal encounter. Cultural material serves as a powerful
therapeutic support, which, when addressed and understood, can dissolve mental blockades
(Martins-Borges & Pocreau, 2009a; Kronsteiner, 2003). Thus, Ethnopsychiatry highlights the
flexibility in methods required to understand the transcultural dynamic, as well as the combination
of psychoanalytic thinking with specific ideas about addressing cultural dimensions in the therapy
43
(Nadig, 2006; Martins-Borges & Pocreau, 2009a; Sturm et al., 2010). According to Nathan (2006),
Ethnopsychiatry accepts the challenge to be changed in its approaches by the culturally determined
mental map of the patients. This way, Ethnopsychiatry is no “closed” theory, but instead a
transformable type of treatment and intervention that is adjustable to the realities of different
countries and cultures and sensible toward nuances and differences (Martins-Borges & Pocreau,
2009a).
Research on mental health support
Psychotherapy research
Psychotherapy research in general has largely been dominated by the question of the
outcomes of psychotherapy and of effective treatments (Lambert, 2013; McLeod, 2011, Zilcha-
Mano, 2018). While it is clearly essential to investigate and establish the effectiveness of any type
of psychotherapy, some have expressed concerns, that the narrow focus of the discipline of
psychotherapy research on quantitative outcome studies may hinder a more comprehensive
understanding of the impact of psychotherapy (Donald & Carey, 2017).
More recently, investigations have been carried out concerned with the question of “what
works well for whom”, thus, in Zilacha-Mano’s opinion, letting the discipline integrate more of the
“complexity of human life” (Zilcha-Mano, 2018, p. 1). Zilcha-Mano (2018) stated that a shift in the
discipline of psychotherapy research has occurred from a focus on diagnosis-specific treatments to
personalised treatments, which attempt to find out “the best practice that may be adapted to a subset of
individuals who share similar characteristics” (Zilcha-Mano, 2018, p. 2). This shift is partially attributable
to the works of Wampold and Imel (2013), who, putting aside the differences between diverse
theoretical orientations and practical approaches to psychotherapy, underscored the importance of
a number of common factors of psychotherapy crucial for positive outcomes across therapeutic
orientations or schools. Wampold and Imel (2015) proposed a contextual model of psychotherapy,
describing the common factors that include empathy, therapeutic alliance and expectation.
According to this perspective, since it is essential that patients accept the proposed explanation for
their distress and consequential therapeutic processes, the treatment should also be adapted to the
particular culture of each patient (Wampold, 2015).
Research on mental health support for refugees
As with the general field of psychotherapy research, refugee mental health research has
mainly consisted of quantitative studies on the efficiency and outcomes of treatments for refugees
(e.g. Schulz et al., 2006; D’Ardenne et al., 2007), especially of trauma-therapy approaches (e.g.
44
Neuner et al., 2004; Paunovic & Öst, 2001). Other studies have been more generally concerned
with the mental health of this group (e.g. Davidson, 2008; Ellis et al., 2008; Fazel et al., 2005) or
with the barriers to access to mental health care (e.g. Asgary & Segar, 2011; Bustamante Ugarte et
al., 2019; Franks et al., 2007). Quite a few guidelines for practice and descriptions of psychotherapy
approaches for refugee patients have also been developed (e.g. Gonsalves, 1992; Koch &
Weidinger-von-der-Recke, 2009; Moro, 2015) exemplified by the “Sonnenberger Leitlinien” that
were developed in Germany (Machleidt, 2006). Meanwhile, some authors have stated that there
continues to be a lack of investigation on mental illness among refugees and immigrants, on
transcultural therapeutic treatment approaches, their efficacy, (Kizilhan, 2006; Wohlfart et al., 2006;
Zaumseil, 2006), as well as on practical models that are sensible toward the specifics of the socio-
political and cultural contexts of refugees (Baron & Schriefers, 2015; Fiechtner et al., 2015;
Hegeman, 2006; Penka et al., 2015).
In particular, there seems to be a Scientist-Practitioner Gap in the field of MHSR or even more
so a Practitioner-Scientist-Gap, as there is very little research that takes into consideration the
perspectives and experiences of the practical experts in the field: psychologists and the refugee
patients themselves (Schweitzer et al., 2015). This poses a problem since refugee patients are the
ones whose thoughts and evaluations on their mental health support – Does it help? Is it useful?
Is it what I expected? Do I feel comfortable? – will ultimately determine whether or not they
continue the treatment and thus, if it is effective. If they do not continue, then the scientific
effectiveness of the treatment will be of no use, since it cannot help a patient who has stopped
attending. Similarly, psychologists providing mental health support for refugees may often be very
aware of and informed about the results of scientific investigations, guidelines for practice et cetera,
but may not feel that these fit or are useful for the reality of their therapeutic practice and the
context and needs of their patients. Professionals may have proper perspectives of therapeutic
processes, ideas of effectivity and outcomes, and strategies to address problems and concerns,
which have developed through their years of practical experiences. Taking these experiences
seriously and treating them as valuable knowledge can thus be a helpful contribution to the
scientific understanding and exploration of mental health support for refugees (Malterud, 2001a).
The need to integrate non-Western perspectives
The comparative study of models of mental health care in different societies provides a unique opportunity for
critical reflection and creative rethinking of current practices.
(Kirmayer, 2012b, p. 160)
45
The section on mental health of refugees provided a glance into the importance of the post-
migration situation and its impacts on refugee mental health. These stressors are primarily shaped
by the societal, juristic, structural, and cultural conditions of the host countries which vary
considerably from country to country (Davidson et al., 2008). This makes the post-migration
experiences and the often-consequential mental health issues of refugees unique to each context
and calls for an investigation of the mental health of refugees in diverse post-migration settings
globally.
Furthermore, societal conditions and culture, together with traditions in psychological
sciences, influence what is considered mentally healthy or pathological (Kirmayer et al., 2015).
Meanwhile, the discipline of psychology itself is dominated by Western countries, in particular by
the United Stated of America in terms of research, publications and knowledge dissemination,
which influences psychological science and practice globally (Adair et al., 2002; Moghaddam, 1987).
For instance, Avasthi (2011) stated that the definitions of normal or abnormal in India are currently
made with reference to ideas of personality structures of Western countries, and people who cannot
be classified according to Western diagnostic models, as they do not fit into any of the categories,
are considered to be suffering from “culture bound” problems. Western theories and concepts,
however, are very much created and embedded in a very specific cultural and historical context
(Gone & Kirmayer, 2010; Marsella 2009).
A reasonable point of view is that all disorders are culture-bound, including all Western disorders since they
emerge, are experienced, and responded to within a cultural context. The question must be asked: Can any
psychological disorder escape cultural influence? The answer is: No!
(Marsella, 2010, p. 19)
Marsella (2009, pp. 25-26) proposed that the ontological and epistemological assumptions
of Western European and North American psychology, which are rooted and continue being linked
to logical positivism and “Enlightenment” ideas, are driven by ten essential factors: experiment-
based empiricism, materialism, male dominance, nomothetic laws, individuality, objectivity,
rationality, reductionism, scientism and quantification and measurement. Meanwhile, these
assumptions and the worldview that rests on them, does not necessarily correspond to (and is
sometimes even in conflict with) perspectives from non-Western countries, which, due to their
own and unique cultures and histories, have different ontological and epistemological assumptions
(Marsella, 2009).
46
The currently authorized nosological categories, consisting of nearly 300 of Million’s splendid fictions, reflect
numerous political, aesthetic, and pragmatic commitments that yield abundant evidence of prescientific or
nonscientific arbitariness – all of which arise as expressions of cultural processes and practices (as indeed
does scientific inquiry itself).
(Gone & Kirmayer, 2010, p. 74)
Like all human experience, psychological suffering and distress, takes its form from cultural
aspects (Gone & Kirmayer, 2010). Arnett (2008) showed, however, that 95 % of the research
published in the six top journals of the American Psychological Association (APA) had been
conducted on European or Usonian participants, even though the WEIRD population (Western,
Educated, Industrialized, Rich and Democratic) has been argued to be among the least
representative samples available for generalizing about human beings (Henrich et al., 2010).
Cultural and societal contexts also influence which sort of mental health support is being offered
and which flourishes in a country (Koç & Kafa, 2018). More than 400 psychotherapy models have
been developed throughout the world (Corsini & Wedding, 2008), but the psychotherapeutic
practice is dominated by a small number of theraputic orientations from Western countries, among
them cognitive behavioural therapy and psychodynamic therapies (Avasthi, 2011; Koç & Kafa,
2018). It is important to investigate to what extent people, and particularly refugees, from non-
Western backgrounds can benefit from available models of mental health support in their new host
countries and what could be useful alternative approaches to the healing of their suffering (Koç &
Kafa, 2018).
The research on refugee mental health and mental health support is, however, similarly
dominated by investigations in Western settings, as is the discipline of psychology itself: Even
though 85% of displaced people are hosted by developing, non-Western countries (UNHCR,
2019), most studies investigating the mental health of refugees and mental health support for
refugees in host countries stem from Western and high-income countries such as the United States
of America (Ong, 1995), United Kingdom (Bogic et al., 2012), Australia (Davidson et al., 2008;
Momartin et al., 2004; Silove et al., 2007), Germany (Comtesse & Rosner, 2019), Canada (Beiser &
Hou, 2016) and the Netherlands (Laban et al., 2008). Some studies have looked at refugee mental
health in middle- or low-income countries such as Bosnia, Uganda and Sudan (see Reed et al.,
2012), but there are few published studies on refugees in Latin American countries (Braga Bezerra
et al., 2019; Moraes Weintraub, 2012; Teixeira et al., 2013). Notable exceptions include studies with
Haitian immigrants in Brazil (Barros, 2016; Barros & Martins-Borges, 2018), Syrian refugees in
Brazil (Jibrin, 2017; Lodetti, 2018), Colombian refugees in Ecuador (Carrasco García, 2010) or in
Chile (Liberona Concha & López San Francisco, 2018) and with Palestinian refugees in Chile (Bijit
47
Abde, 2012). This prevalent selective geographical bias leads, on the one hand, to mental health
concerns being defined by high-income countries (Kirmayer & Pedersen, 2014). On the other hand,
it also limits our understanding of mental health and illness, as particular views and
conceptualisations on normality, personhood, self and healing are being perpetuated (Kirmayer,
2007). There is an urgent need to broaden our horizons and open up our perspectives by fostering
and disseminating psychological research and knowledge from a greater variety of contexts and
cultures, particularly, concepts and perspectives on psychopathology, mental health and healing.
The Dissertation
Aims of the dissertation

This dissertation aims to contribute to the bridging of the scientist-practitioner gap and to the
integration of non-Western perspectives of mental health support for refugees into the scientific
literature. In particular, the objective of this thesis is to learn from refugee patients and experts12
internationally, to better meet the challenges of mental health support for refugees.
Thus, there are two main focal points to this dissertation:
1. The experiences of refugee patients and psychologists who work with refugee patients, and
2. The knowledge and experiences of professionals who work with refugee patients in a non-
Western country, namely Brazil.
The research questions, are:
Section I: What have qualitative studies found to be hindering and helpful elements in the mental
health support for refugees as experienced by refugee patients and professionals?
Section II:
1. What do psychologists in Brazil perceive to be psychological suffering and mental health
problems in their refugee patients? In particular,
a. How do they describe the suffering?
b. Which mental health disorders and symptoms do they perceive to be most common
among their refugee patients?
2. How do psychologists in Brazil experience the psychological care of refugees? In particular,
12 The term expert as applied here, follows the conceptualisation of Meuser and Nagel (2002), who define experts as
people who form part of the sphere of activity under investigation. Being an “expert” involves carrying some sort of
responsibility for the design, implementation or control to a solution of a problem, or privileged access to information
about a certain type of process or group of people. Psycho-social professional who work with refugee patients are
labelled experts in this thesis, since they have specialised knowledge and privileged information on refugee patients and
their mental health support, and carry responsibility for the implementation of therapeutic interventions.
48
a. What do they see as negative aspects or barriers in the care process?

b. What do they see as positive aspects or facilitators in the care process?
c. What do they see as necessary changes to better the psychological care for refugees
in Brazil and ultimately refugee patients’ mental health?
3. What do psychotherapists who conduct psychotherapy with refugees in Brazil perceive as
supportive and as hindering elements in their work?
Disciplinary and epistemological localisation and methodology of the

dissertation
The dissertation is best thought of as a contribution to a cultural-clinical psychology (Ryder et
al., 2011). Clinical psychology aims to understand, assess and treat psychological and behavioural
problems and disorders by using the principles of psychology (Plante, 2005). Cultural psychology aims
to investigate cultural and ethnic sources of diversity in psychological functioning, emotion,
somatics, moral evaluations, human development, and self-organisation (Shweder & Sullivan,
1993). Cultural psychology emerged especially from the intersection of social and developmental
psychology with sociology, anthroplogy, history, edcuational sciences and sociolinguistics. The
discipline revolves around the core claim that human psychology and culture are grounded in each
other or, in other words, that the mind and culture mutually constitue each other (Ryder et al.,
2011). Thus, the discipline focuses on humans’ intentional construction of meaning and among
other things, looks at the influence of social norms on the organisation of the psyche (Valsiner,
2013). The combination of cultural and clinical psychology enriches theory and research in both
separate fields – cultural psychology, on the one hand, can support clinical psychology to move
beyond “conceptualisations of mental illnesses as products of solitary minds to thinking of it as contextually
embedded in networks of local meanings, norms, institutions, and cultural products.” (Ryder et al., 2011, p. 963).
On the other hand, clinical psychology allows advances in cultural psychology, since the study of
what is considered “abnormal” or psychopathological in a certain society reveals much about the
society’s culture, and about cultural processes that are in place when the “normal” cultural scripts
fail to work (Ryder et. al., 2011).
In line with the focus of cultural psychology, the present dissertation departs from a
constructivist paradigm, which stresses the social production and reproduction of knowledge,
experience and meaning (Braun & Clarke, 2006; Levers, 2013; Whitley, 2012):
49
The notion of the world being 'constructed' implies that we inhabit a social, personal and relational world
that is complex, layered, and can be viewed from different perspectives. This social reality can be seen as
multiply constructed. We construct the world through talk (stories, conversations), through action, through
systems of meaning, through memory, through the rituals and institutions that have been created, through the
ways in which the world is physically and materially shaped.
(McLeod, 2011. p. 2)
In other words, since the aim of this thesis is to understand the experiences of refugee patients and
professionals, and specifically those of psychologists in Brazil, how the participants make sense,
perceive and construct their experiences becomes of vital importance. Consequentially, the
epistemology of the dissertation is subjectivist, meaning that knowledge is recognised as value
laden, since it is “always filtered through the lenses of language, gender, social class, race, and ethnicity” (Denzin
& Lincoln, 2005, p. 21). Finally, this dissertation was informed by a phenomenological
methodology, as a guiding framework attempting to obtain a window into and describe insiders’
experiences of the mental health support for refugees (Chang & Berk, 2009; McLeod, 2011). Thus,
qualitative methods of inquiry, which are rooted on the premise of a generation of knowledge based
on human experience (Sandelowski, 2004) and the value of insiders’ views (Omidian, 2000), were
used. Apart from being consistent with the philosophical underpinnings of this dissertation,
qualitative methods allow for an in-depth analysis of participants’ perspectives – they can be used
to understand the lived day-to-day experiences of participants (Whitley, 2012) and the meaning of
phenomena as experienced by the participants themselves (Malterud, 2001a). Although the fields
of psychological and psychiatric research are currently dominated by quantitative methods, these
methods have certain limitations in capturing the complexity of human experience – results may
be statistically significant, but, and particularly in the context of clinical practice, superficial and not
representative of professionals’ daily work with patients (Guba & Lincoln, 1994; McLeod, 2011).
Derek Summerfield, famous for his critique of the presupposition that Western psychiatry is
universally valid and of the medicalisation of human experience (Summerfield, 2008, 2012),
recommended prioritizing qualitative inquiry as this would “promote more grass roots ownership of the
terms of reference of mental health and enable a robust and relevant knowledge base to emerge” (Summerfield,
2008, p. 994). Furthermore, qualitative methods allow to gain insights into “explanatory models” of
patients and practitioners (Kleinman, 1980). This concept from medical anthropology stresses the
importance of causal attributions and ethnophysiological theories on illness experience, but also
on treatment response (Kirmayer & Sartorius, 2007; Watters, 2001). The use of qualitative methods
also shows the intention of a discovery-oriented approach, which is recommended in a novel,
complex, pluralistic and multicultural context (Bernal, 2001). This becomes especially relevant in
50
the second section of this thesis, since the second section focuses on psychologists’ experiences in
providing MHSR in the Brazilian socio-political and cultural context, which has not been
investigated before.
Section I: A Qualitative Evidence Synthesis

The first section of this dissertation takes a look at the qualitative literature: what have other
researchers found to be experienced as hindering and helpful aspects in the MHSR by patients and
professionals? The section is not a pure literature review, however, but rather a “Qualitative Evidence
Synthesis” (QES; Barnett-Page & Thomas, 2009; Jensen & Allen, 1996; Karageorge et al., 2017;
Paterson, et al., 2001; Williams & Morrow, 2009). “Qualitative Evidence Synthesis” is an umbrella term
suggested by Booth (2016), referring to the various methods that have been developed as tools to
synthesise qualitative studies on a meta level. The approach of QES chosen for this thesis was
orientated toward the meta-study method (Paterson et al., 2001) and thematic synthesis (Thomas
& Harden, 2008), which will be explained in more detail in Chapter 2. As a quantitative meta-
analysis, QES can be a means to combine the knowledge of individual studies. This has increasingly
become of interest to qualitative health researcher, especially in the context of research on users’
experiences. QES addresses one of “the main weaknesses of qualitative methodologies” (Heymann, p.
1576): the generation of an increasing amount of individual studies. In contrast to systematic
reviews, they are more interpretative than aggregative (Paterson et al., 2001) and allow for going
beyond the results of a single study (Thomas & Harden, 2008; Timulak, 2009). In
psychotherapeutic research, the use of qualitative evidence synthesis is relatively new (Timulak,
2007, 2009). Chapter 3 will thus provide a methodological reflection on the use of QES and of
certain challenges that arrive in the process.
Section II: Semi-structured interviews with experts
The tacit knowledge held and applied by proficient practitioners, however, represents a valuable form of
clinical knowledge, which has been acquired through experience, and which should be investigated, shared,
and contested.
(Malterud, 2001a, p. 397)
The second section of this dissertation is based on semi-structured interviews that were
conducted with psychologists who work with refugees in Brazil. Such interviews allow participants
to talk about predetermined topics without limiting their potential responses to predetermined
possibilities (Groleau et al., 2006). The importance of investigating the experiences of professionals
stems inter alia from the assumption that research could benefit from making the implicit
knowledge of clinicians explicit, as these professionals, while treating patients, gain and constitute
51
clinical knowledge and make their own experiences and adjustments to treatment and diagnosis in
everyday practice (Malterud, 2001a). Professional psychologists are thus treated not as private
persons, but as experts for their work context (the MHSR) who possess abstract, technical and
professional insight, as well as specialist knowledge (Helfferich, 2005; Meuser & Nagel, 2002, 2009).
For the investigation, gatekeepers and snowball sampling were used as recruitment
strategies (Helfferich, 2005). We planned on conducting sufficient interviews to reach a point of
data saturation, which, according to Guest et al. (2006) happens within the first 12 interviews.
During the actual interview phase, however, we constantly reflected upon data saturation and the
size of our sample, and was open to change and adapt the final sample size (Guettermann, 2015;
Onwuegbuzie & Leech, 2007). The concept of data saturation is debated in the qualitative literature
and some authors have argued that researchers often end the data collection phase too early
(Saunders et al., 2018). As new issues arose in interviews, even after conducting the minimum
required number of 12 interviews, data collection was continued until we ended up with 32
interviews in total. This final point of data collection was set, because no new aspects appeared and
because collecting even more data might have limited our capacity to analyse the data in detail and
draw conclusions (Guettermann, 2015; Onwuegbuzie & Leech, 2007, Saunders et al., 2018).
All of these 32 interviews were conducted with psychologists, 18 of which also declared to
work as psychotherapists13. More information on the participants and the interviews will be
provided in the following chapters 4-7. All of the 32 interviews were fully transcribed and analysed
in a dominantly inductive manner (even though it is contested to which extent any analysis of a
researcher who is familiar with the scientific literature on a topic can ever be fully inductive, see for
instance Braun & Clarke, 2012). The experiences of psychologists in psychological care and
psychotherapists were analysed together (Chapter 5) for an investigation of their perspectives on
the psychological suffering of their refugee patients. In doing so, attention was paid to potential
differences arising from diverging contexts of work. Subsequentially, the experiences of
psychologists in psychological care and psychotherapists were analysed separately and resulted in
two different articles (Chapter 6 and Chapter 7), as even though the research questions were similar,
the contexts in which psychotherapists and psychologists in psychological care worked as well as
the approaches and objectives of their MHSR differed considerably. For instance, psychotherapists
13 The differentiation between psychotherapists and psychologists in psychological care is difficult and contested in some
contexts (see previous section, pp. 40-41, and McLeod, 2011). There is no formal license for psychotherapists in Brazil,
and psychologists can work psychotherapeutically after finishing their university degree. Therefore, participants were
asked to self-define their work, and only participants who declared their work to be clinical (“trabalho clínico”) and
psychotherapy (psicoterapia) were defined as “psychotherapists”. On the other hand, participants who stated their
work was non-clinical psychological care work (“acolhimento”; “aconselhamento”) were referred to as psychologists
working in psychological care.
52
often had a long-term treatment orientation and aimed to work with patients predominantly on
their psychological concerns, even though this was not always possible as will be explicated in
Chapter 6. Psychologists in psychological care sometimes only saw patients as few as one or two
times and perceived their work to be much more to be an emergency-intervention, rather than
deep psychological treatment (see Chapter 5). However, both professions form part of the mental
health support that is offered to refugees in Brazil who have psychological concerns and certainly,
many of the experiences of psychologists in psychological care and psychotherapists overlap. This
will be discussed in detail in Chapter 7.
The methodical approaches that guided the data collection and analysis of the interview
transcripts were consensual qualitative research (CQR, Hill et al., 2005) and thematic analysis
(Braun & Clarke, 2006; Braun et al., 2014). CQR is an inductive approach using open-ended
questions in semi-structured interviews and consensus of the research team, and is characterised
by the integration of multiple viewpoints (fostered by the use of several judges) and the importance
it gives to context (Hill et al., 2005). It combines aspects of phenomenology (Giorgi, 1985),
grounded theory (Strauss & Corbin, 1998) and comprehensive process analysis (Elliott, 1989) and
incorporates a constructivist ontology and postpositivist philosophical underpinnings (Hill et al.,
2005), which, for instance, become visible in the role of the interviewer:
The interviewer’s role is typically as a trustworthy reporter trying to uncover what the participant truly
believes, rather than as someone who engages with the participant in a deeply relational way to coconstruct
meaning.
(Hill et al., 2005, p. 197)
In this approach researcher’s biases or positionality are disclosed and reflected upon. In the
analytical procedure, the researchers look for themes across cases (=participants) and a research
team comes together to discuss findings, making use of consensus to create their interpretation of
the research data (Hill et al., 2005).
Thematic analysis is a method of data analysis only (Braun & Clarke, 2012); a process of
looking for “repeated patterns of meaning” across a data set (Braun & Clarke, 2006, p. 15). It is a widely
used method that is not bound to a specific theoretical framework, and can be deployed flexibly
across theoretical and epistemological approaches (Braun & Clarke, 2006). In a way, thematic
analysis allows for the organisation and structuring of the data, but also goes deeper – it helps the
researcher to make sense of the data, that is “collective or shared meanings and experiences” (Braun &
Clarke, 2012) and construct an interpretation across cases (Braun & Clarke, 2006). In this
dissertation, thematic analysis was followed as a guideline to identify, analyse, and report patterns
53
– called themes – within the entire data set. These themes were identified in an inductive or “bottom-
up” approach, in order to allow for themes to be firmly linked to the interview data (Patton, 1990).
In an inductive analysis, qualitative researchers start the analysis without a coding framework
in mind. Instead, they begin the analytical process by familiarising themselves with the data set,
studying it in-depth and making evidence-based inferences about labelling, organising and
hierarchising codes and themes (Finfgeld-Connett, 2014). The focus of the present investigation
was an analysis of the entire data set (in contrast to the deep analysis of a single theme), which is
recommended in research areas that have not received much attention yet, or in studies with
participants whose perspectives on the issues are still unexplored (Braun & Clarke, 2006). In
thematic analysis, what is defined as a theme depends on the decision of the researchers, but needs
to be consistent. A theme is very prevalent across the data set (either because a large number of
participants refer to it or because it takes up a considerable portion of the interview transcripts)
and/or carries a sort of “keyness” to the data, capturing an important aspect to answer a research
question (Braun & Clarke, 2006).
In this dissertation, the methodical steps recommended by Braun and Clarke (2006, 2012:
data familiarisation, initial coding, searching for themes, reviewing themes, defining and labelling
themes, producing the report) were undertaken during the analytical procedure. Furthermore, some
recommendations of CQR (e.g. to let several researchers judge the data interpretation) were
followed, including the guidelines for data collection (semi-structured interviews). Additionally,
following the initial (open) coding phase an axial coding phase was implemented. Thus, using a
combination of CQR and thematic analysis, the analytical process of the interview data collected
for the purpose of this dissertation consisted of two coding phases:
1. Open line-by-line coding was used to develop an (inductive) coding tree with codes,
subthemes and themes from the interview transcripts.
2. Axial coding was used to reapply the fully developed coding tree to the data. A
miscellaneous category was kept in order to account for codes and themes that might
have been overlooked during the open coding phase.
The axial coding, which was undertaken using the computer software MAXQDA (VERBI-
Software, 2020), allowed to obtain frequency counts, thus making it possible to establish how many
times a code, subtheme and theme were mentioned by participants. This quantitative extension of
thematic analysis (Livingston et al., 2019) was used to allow for an overview of the representation
of each theme in the complete data set. It does not allow for inferences of statically valid prevalence
(Malterud, 2001b).
54
Section I
Mental Health Support for Refugees –

Experiences of Professionals and Patients
Chapter 2
A Qualitative Evidence Synthesis of Refugee
Patients’ and Professionals’ Perspectives on
Mental Health Support
Published as
Duden, G.S., Martins-Borges, L., Rassmann, M., Kluge, U., Guedes Willecke, T. and Rogner, J.
(2020). A Qualitative Evidence Synthesis of Refugee Patients’ and Professionals’ Perspectives on
Mental Health Support. Community Psychology in Global Perspective, 6(2/1), 76-100. Doi:
10.1285/i24212113v6i2-1p76
Section I | Chapter 2 A Synthesis
Abstract
To generate a more comprehensive understanding of mental health support for refugees, a
qualitative evidence synthesis of studies examining professionals’ and patients’ perspectives was
conducted. The aim was to identify what refugees and psycho-social professionals working with
refugees perceived as positive/helpful and negative/hindering in the therapeutic process. Six
electronic databases were searched, followed by citation tracking. Of the 711 studies found, 10
studies were selected for a thematic synthesis based on inclusion criteria such as being qualitative
research reports published after 1998. From these studies, referring to 145 insider perspectives,
descriptive themes were developed and subsequently synthesised into 13 analytical clusters. The
results highlight the importance of a trusting therapeutic relationship, of the adaptation of
therapeutic approaches to patients’ needs and situation and of psycho-social support, of cultural
sensitivity and external support structures for professionals. Negative or hindering aspects were
identified as a lack of mental health care structures, the impact of the post-migration situation on
patients’ well-being, cultural and language differences, and a context of mistrust and negative
experiences. Finally, ambivalences were formulated regarding verbal therapies, trauma exposure,
the benefit of mental health care, and the impacts of this work on professionals. Results are
discussed in relation to flexible therapeutic boundaries. Suggestions are made for practice, such as
using integrative approaches that focus on psychoeducation and transparency, and for future
research, such as investigating psychotherapy with refugees in non-Western countries.
Keywords: Refugees, Transcultural Psychology, Systematic Review, Intercultural Research,

Qualitative Evidence Synthesis
57
Introduction
Currently, more than 79.5 million people around the globe are forcibly displaced trying to
escape from wars, violence, and persecution (UNHCR, 2019). Certainly not all of these displaced
people become mentally ill, and many show profound resilience (Papadopoulos, 2007) considering
the challenges associated with dislocation. Nevertheless, augmented levels of psychological distress
(De Anstiss et al., 2009; Lindert et al., 2009) are a common consequence of experiencing the “social
dramas of war, violence, displacement” (Eastmond, 2000, p. 72), and the difficulties faced in
resettlement countries (Beiser, 2009; Fazel et al., 2005; Hassan et al., 2016; Murray et al., 2010;
Sandhu et al., 2013). Especially high rates of posttraumatic stress disorder, sometimes reported to
be up to 10 times higher than in the general population, as well as elevated rates of depression,
anxiety, chronic pain and other somatic complaints, have been described among refugees14 (Fazel
et al., 2005; Keyes, 2000; Kirmayer et al., 2011; Lindert et al., 2009; Steel et al., 2009). As untreated
psychological suffering can lead to somatisation and a decrease in the chance of recovery (Schouler-
Ocak, 2015), particular attention should be paid to provide adequate psychological support for
refugees resettling in new countries (Kluge, 2016; Kronsteiner, 2017; Ward et al., 2005).
In recent years, literature focusing on mental health support (MHS) for refugees has
increased. For instance, the importance of cultural sensibility or humility (Kirmayer, 2012a;
Tervalon & Murray-Garcia, 1998) and of a recognition of the socio-political context of clients
(Droždek, 2007; Metzl & Hansen, 2014; Watters, 2001) has been stressed. Some have argued that
addressing refugees’ complex needs in MHS through psycho-social and interdisciplinary work,
advocacy and practical assistance is particularly helpful (Karageorge et al., 2017; Watters, 2001).
Furthermore, the role of trust and the therapeutic relationship (Sandhu et al., 2013) have been
emphasised as well as the high impact MHS can have on professionals’ own mental health
potentially leading to vicarious traumatisation or resilience (Barrington & Shakespeare-Finch,
2013). A number of qualitative studies have focused on the perspectives of “insiders” (Ahearn,
2000a; Barrington & Shakespeare-Finch, 2013, 2014; Pugh & Vetere, 2009), i.e. of refugee patients
and the psycho-social professionals15 (PSPs) themselves (Karageorge et al., 2017; Kramer, 2005).
14This article uses the terms “displaced people” and “refugees” interchangeably and does not differentiate between people’s official
civil statuses in resettlement. The term “asylum-seekers” is only used when the difference between already officially recognised
refugees and asylum-seekers, who are still waiting for their claim to be processed, is of importance.
15The term psycho-social professional (PSP) as used in this article does not follow any specific standardised definition. It was chosen
here since studies investigating perspectives of MHS professionals on psychotherapy with refugees are still sparse and the unifying
term “PSP” allows for an inclusion of a wide range of professional labels including “psychotherapist,” “counsellor,” and
“psychologist.” It also allows for a better integration of international studies, as more specific professional labels, such as
“psychotherapist”, may have diverging conceptualisations and understandings across countries.
58
Such research holds the potential to foster epistemological plurality in psychotherapy research in
general (Castonguay, 2011) and, more specifically might help to overcome ethnocentric limitations
(Patel, 2003a; Speight, 2012) and shed light on what is supporting refugee patients and their PSPs
in the therapeutic process (Guregård & Seikkula, 2014; Kramer, 2005; Watters, 2001).
In qualitative health research, especially in the context of users’ experiences, there has been
a rising interest in qualitative evidence syntheses (QES; Barnett-Page & Thomas, 2009; Jensen &
Allen, 1996; Karageorge et al., 2017; Paterson et al., 2001; Williams & Morrow, 2009). As a
quantitative meta-analysis, QES can be a means to combine the knowledge of individual studies.
In contrast to systematic reviews, they are more interpretative than aggregative (Paterson et al.,
2001) and allow for going beyond the results of a single study (Thomas & Harden, 2008; Timulak,
2009).
To our knowledge, as of the writing of this article, only one paperhas systematically
reviewed qualitative studies about the experiences of refugees and staff concerning MHS services
(Karageorge et al., 2017). The authors analysed 11 studies and developed the core concepts:
“Mutual understanding, addressing complex needs, discussing trauma, and cultural competence”,
which were each associated with enabler and barrier themes. For instance, “exploring clients’
culture” and “practical interventions” were seen as enabling, whereas refugees having “more
pressing concerns than talking” was considered a barrier to MHS. Furthermore, “discussing
trauma” was an ambivalent topic among staff and clients – sometimes regarded as helpful in
creating meaning, sometimes considered difficult and seen in relation to vicarious traumatisation
in staff. Similar to Karageorge et al. (2017), the aim of the present study is a deeper understanding
of MHS with refugees as experienced by staff and users. However, the focuses of this article are
the helpful (positive) aspects as well as the hindering (negative) aspects that patients and PSPs face
in the therapeutic process. Therefore, this research will synthesise qualitative interview studies that
have been published in the last 10 years, investigating refugees’ and PSPs’ perspectives on the topic.
To allow for an unconfounded comparison with the review by Karageorge et al. (2017) only studies
that were not analysed by these authors will be included in the current QES. Also, in order to foster
intercultural perspectives on such an intercultural topic (Britten et al., 2002), this QES will search
for studies published in several languages and in varied international databases. The two leading
research questions are:
a) What do patients and PSPs perceive as positive/helpful aspects of MHS?
b) What do they perceive as negative/hindering aspects of MHS?
59
Method
“Qualitative Evidence Synthesis” (QES) approach

Qualitative Evidence Synthesis” (QES) is an umbrella term suggested by Booth (2016),
referring to the various methods that have been developed as tools to synthesise qualitative
studies on a meta level. The approach of QES chosen here was orientated toward the metastudy
method (Paterson et al., 2001), and thematic synthesis (Thomas & Harden, 2008). The meta-study
method was selected for this study because it has a constructivist epistemology, posing the question
of how participants construct their experience, researchers their results and meta-researcher the
results of the results (Paterson et al., 2001). This is in line with the insiders’ perspective in primary
research, which focuses on the in-depth knowledge constructions of individuals. As the aim of this
QES was to investigate the experience of PSPs or refugee patients, thus concentrating on primary
studies following a constructivist insiders’ perspectives approach, the use of the meta-study method
allowed for a compatibility in epistemology and avoided violating the integrity or philosophical
bases of the primary studies (Booth et al., 2016). Paterson et al.’s (2001) description of the method
was taken as a practical guideline during the data collection process. Thematic synthesis guided the
analysis process of this QES as it focuses on the inclusion of a narrow range of methodologies in
primary studies (Booth, 2016). Thematic synthesis follows a critical realist epistemology and
includes stages of coding secondary data from multiple studies, of generating and of interpreting
the recurring themes. Both QES approaches go beyond summarising relevant studies with the aim
of generating new results through the transference of themes across studies (Barnett-Page &
Thomas, 2009; Jensen & Allen, 1996; Paterson et al., 2001).
Researchers’ backgrounds
The primary researcher of this project is a German psychologist and PhD candidate fluent
in all the languages that were included in the QES. She has experience working in the MHS of
refugees in Germany and Brazil. The other researchers and co-authors who were involved in the
selection of studies, coding, and theme development process are all German or Brazilian
psychologists, and some have worked over 20 years in the MHS of refugees, mostly in Brazil,
Canada and Germany.
Sampling
Between November 2017 and February 2018, six databases were searched for relevant
research reports: Web of Science, PsycINFO, EBSCO, Psyndex, Repère, and Redalyc. The first
60
three are mainly English language-based databases. Psyndex is a database used in German speaking
countries while Repère primarily presents articles from francophone countries and Redalyc articles
from Ibero-America. The selection of databases was based on the intention to provide an
internationally inclusive view on the topic. Nevertheless, we acknowledge that this selection might
have led to firstly, a bias towards English-language articles and secondly, to the omission of some
relevant articles. The keywords “refugee AND psychotherapy OR counselling OR mental health
service AND qualitative” were used in a full text search, as well as their German, French,
Portuguese and Spanish equivalents. The sampling strategy was exhaustive in the sense that all
studies that responded to key word search were considered for inclusion. During the selection
process, the “Primary Research Appraisal Tool” (Paterson et al., 2001) was used to keep structured
summaries of each study and to check the coherence and appropriateness of the primary studies’
aims, methodology and interpretations (Paterson et al., 2001; Tong et al., 2012).
Inclusion criteria
The inclusion criteria for the primary studies were formulated according to the research
questions. Articles had to be original qualitative research reports published in peer-reviewed
journals (Timulak, 2009) after 1998 and written in English, German, French, Portuguese or
Spanish. Only studies that investigated MHS as experienced by the PSPs or refugee patients were
included. Therefore, study participants had to be either patients with a refugee background or PSPs
working with refugees. Also, studies were considered exclusively if participants did not live in
refugee camps, but instead had resettled or were living in communities in host countries. As the
data retrieval yielded few primary studies investigating patients’ experiences, we decided to include
the perspectives of asylum-seekers as well as those of officially recognised refugees, thus not
considering people’s official civil status in resettlement. In terms of methodology, this QES
concerns itself solely with interview studies, following Jensen and Allen’s (1996) suggestion to focus
on primary studies with a single method. The authors argue that including diverse methods might
lead to difficulties for comparability as methods are based on different ontologies and
epistemologies (Jensen & Allen, 1996). Decisions on the inclusion of studies were discussed among
the research team members.
Description of included studies and their participants

A total of 685 articles were found across the six databases (Portuguese keyword search
yielded 65 articles, Spanish 114, German 54, English 303, and French 149). Additionally, another
26 English language articles could be identified from citation tracking. Of these 711 studies, 638
were excluded based on their titles being either not relevant to the research question (n=514) or
61
duplicate records (n=124), and another 35 were excluded after examination of the abstracts (see
Figure 416). A total of 38 studies were assessed for eligibility by reading the full text and using the
“Primary Research Appraisal Tool” (PRAT, Paterson et al., 2001) as well as Thomas and Harden’s
(2008) 12 criteria for methodological quality assessment. The PRAT is a form that assists in coding
and storing information on the primary studies related to their theoretical frame and
methodological congruency such as by evaluating sampling, data analysis and interpretation
procedures (see Paterson et al., 2001 for an example PRAT). The 12 criteria by Thomas and Harden
(2008) evaluate three main aspects of quality: the adequate descriptions of the whole study (e.g.
aims, methods, findings), the reliability and validity of methods of data collection and analysis, and
finally, the appropriateness of the study’s methods to guarantee that the data is based on
participants’ own perspectives. In the majority of excluded cases, the study participants were
neither refugee patients nor PSPs or articles represented therapy guidelines.
Figure 4
PRISMA flow diagram. Adapted from Moher et al. (2010)
16
The numbers of the figures and tables in the articles were adjusted to continue the sequence of numeration of the
whole thesis.
62
Two studies were excluded from analysis as they did not meet the quality criteria due to
their methodology being reported with insufficient clarity. Finally, 10 studies remained for inclusion
in the QES: All of them met the laid-out quality assessment criteria and differed from the ones
chosen by Karageorge et al. (2017). Only one of the studies was a non-English language report.
The details of the studies are summarised in Table 1, characteristics of the samples are provided in
Table 2. This QES included 145 participants of 10 analysed studies in total, of which 68 were PSPs,
54 refugees with a granted asylum status in the host country and 23 asylum-seekers. 15 of the
participants were minors.
Data use and analysis

As suggested by Paterson et al. (2001) all information available in the results sections of the
studies was used. As the first step of the analysis, the same data set, i.e. the results sections of the
10 studies were each coded line by line by the first author of this article and two other independent
coders using MAXQDA 2018 (VERBI-Software, 2007). In the case of studies that involved the
perspectives of other participants, such as interpreters, only the parts clearly attributable to patients
or PSPs were coded. To approach the data inductively, the research questions were temporarily set
aside (Thomas & Harden, 2008). The second step was the development of descriptive, data-driven
themes. Coders independently grouped primary codes into hierarchical structures that
distinguished between patients’ and PSPs’ perspectives. The findings of this inductive part showed
that several elements were not clearly positive or negative but rather experienced ambivalently by
participants, which is why a third research question about “ambivalent aspects” was put into place.
The third methodological step was organising the descriptive themes into analytical clusters that
answered the QES questions. The descriptive themes of PSPs and refugees were compared and
grouped together, ultimately forming a hierarchical analytical framework. The decision of bringing
together the experiences of PSPs and refugees was based on the finding that experiences tended to
overlap. Records were kept if the descriptive themes related to the accounts of patients, PSPs, or
both (see Table 3). The coders worked independently in English on all steps and subsequently
discussed their findings until consensus about the themes and their structures and labels was found
(Braun et al., 2014; Hill et al., 2005; Paterson et al., 2001; Thomas & Harden, 2008). As a final step,
the primary data were coded a second time, this time deductively by applying the previously
developed analytical framework. A “miscellaneous” category was kept to avoid overlooking themes
that might have been omitted in former steps. This last step was undertaken by two new
independent coders and the first author of this article.
63
Table 1
Characteristics of the studies included in the synthesis
Authors, Date Origin Research Focus Analysis Sampling MHS Strategy/Status
Al-Roubaiy et al., 2017 Sweden Ps’ reasons for seeking therapy, perceptions of IPA (Smith et al; 2009)a purposeful n.s.
therapist, process & outcome. homogeneous
sampling
Maier & Straub, 2011 Switzerland Ps’ concepts & attitudes about illness & CA (Mayring, 1990) maximum variation multimodal clinic; ≥10 sessions,
appropriate treatment. sampling still under treatment.
Majumder et al., 2015 UK Unaccompanied minors’ views’ on mental TA (Boyatzis, 1998) Recruited through specialist child & adolescent
health & MHS. local authorities MHS, n.s.
Mirdal et al., 2012b Denmark Ps’ & PSPs’ perceptions of curative & QPA (Girogi, 1985) selective sample short-term PDT existential &
hindering factors in psychological therapy. cognitive therapy; therapy
terminated
Puvimanasinghe et al., 2015 Australia PSPs’ experiences of MHS, healthcare & TA (Braun & Clarke, n.s. 5 working in healthcare, 11 in
resettlement when working with refugees. 2006) MHS, 10 in resettlement
Schweitzer et al., 2015 Australia PSPs’ conceptions & experiences of therapy TA (Braun & Clarke, Snowball sampling n.s.
with R 2006)
Thöle et al., 2017 Germany PSPs’ perspectives of the difficulties in the GTA (Glaser & Strauss, Through independent practice,
psychotherapy with refugees. 2010) governmental behavioural,
institutions & PDT, PA, (12 additionally TT)
NGOs
Valibhoy et al., 2017 Australia Ps’ experiences of access & process of TA (Braun & Clarke, purposeful multiple services, 8 under
Australian MHS. 2006) sampling; treatment, 8 former patients
snowballing
Vincent et al., 2013 UK Acceptability of TFCBT by exploring the IPA (Smith & Osborn, TFCBT, ≥5 sessions in the last 6
purposeful
experience of the therapy for asylum-seekers 2003) homogeneous
months
with PTSD. sampling
Warr, 2010 UK PSPs’ perspectives of beneficial counselling GTA (Strauss & Corbin, convenience sample
counsellors & specialised care
approaches for refugees. 1998) providers; n.s.
Note. CA = Content Analysis; GTA = Grounded Theory Analysis; IPA = Interpretative Phenomenological Analysis; MHS = Mental Health Support, n.s. = not specified; P = Patients;
PA= Psycho-Analytic Therapy; PDT = Psycho-Dynamic Therapy; PSPs = Psycho-social Professionals; TA = Thematic Analysis; TFCBT = Trauma-Focused Cognitive Behavioural
Therapy; TT = Trauma Therapy; QPA = Qualitative Phenomenological Analysis.
aAll references refer to citations within the primary articles and will not be enlisted here.
b Only the results section related to the PSPs and patients were analysed in the study. Interpreters’ parts were excluded from analysis.
64
Table 2
Characteristics of the participants in primary studies
Study Number of Nationalities Gender Age (years) Asylum Status Duration in host country
Participants (years)
Al-Roubaiy et al., 2017 10 P Iraq (10) M: 10 Mean: 32 Refugees Mean: 10.2

Range: 21-51 Range: 5-20
Maier & Straub, 2011 13 P Afghanistan (2), Bosnia (2), Cameroon (1), W: 5 Mean: 37 Asylum-seekers: 8 Mean: 5.1
Chechnya (1), Iran-Kurdish (2), Kosovo (2), M: 8 Range 22-35 Refugee: 5 Range: 1.5 to 17
Turkey (1), Turkey-Kurdish (1), Sudan (1)
Majumder et al., 2015 15 P Afghanistan (11), Eritrea (1), Iran (2), Somalia (1) W: 1 Mean: 16.7 Asylum-seekers: 8 n.s
M: 14 Range: 15-18 Refugee: 7
Mirdal et al., 2012 16 P, 4 PSP, (8 PSP: Denmark (4) PSP: 4 W PSP: n.s. Refugees n.s
interpreters) Refugees: Afghanistan (1), Bosnia (5), Iraq (6) Refugees: Refugees - Mean:
Lebanon (1), Palestine (1), information missing W: 9 39
(2) M: 7 Range: n.s.
Puvimanasinghe et al., 2015 26 PSP 16 mainstream Australian, 5 Refugee W: 18 n.s Not applicable Not applicable
Background (Asia, Europe, Middle East), 5 M: 8
Immigrant Background (Asia, Europe, Middle
East, South America)
Schweitzer et al., 2015 12 PSP 7 Australian born W: 10 n.s Not applicable For not Australia
5 born outside Australia M: 2 born - Mean: 17
Range: 3-34
Thöle et al., 2017 20 PSP 4 with own immigration/flight experiences, n.s. W: 15 Mean: 54 Not applicable Not applicable
M: 5 Range: 42-70
Valibhoy et al., 2017 16 P Afghanistan, Côte d’Ivoire, DR Congo, Ethiopia, W: 9 Mean: n.s. Refugees Mean: 5.2 years
Iraq, Iran, Pakistan, Sudan, Tanzania (no M: 7 Range: 18-25 Range: 1.5- 12.3
information of distribution)
Vincent et al., 2013 7P Afghanistan (1), Burundi (2), Iraq (1), Sudan (2), W: 3 Mean: 29 Asylum-Seekers Mean: 3.2
Zimbabwe (1) M: 4 Range: 22-42 Range: 0.5-10
Warr, 2010 6 PSP n.s. n.s n.s Not applicable Not applicable
Note. M = Men; n.s. = not specified; P = Patients, PSP = Psychosocial Professionals; W = Women.
65
Results
Analytical clusters
Based on the 10 included studies referring to the perspectives of 68 PSPs and 77 refugee
patients, five analytical theme clusters were synthesised to answer the first question
(positive/helpful), four clusters to answer the second question (negative/hindering), and four
clusters concerning ambivalent aspects. This third category was put into place because the inductive
data analysis showed that several elements were repetitively discussed in an ambivalent way. The
analytical clusters are depicted in Figure 5. Table 3 shows the descriptive themes organised into the
analytical clusters. Only two clusters were based exclusively on the perspectives of PSPs (cluster
C4) or patients (cluster B3). The relationships between analytical clusters are depicted in Figures
6a-e. The primary studies included a diversity of MHS professions, but when comparing the
descriptive themes across the studies, no clear differences between psychotherapists’ perspectives
and other MHS professions were found. Furthermore, the patient samples of the primary studies
were heterogenous within each study (see Table 2, the exception being Al-Roubaiy at al. (2017)
who focused on male refugees from Iraq only) and across studies including refugees and asylum-
seekers of diverse origins, genders and age groups and suffering from different kinds of mental
health problems. As most studies focused on commonalities among their participants, or stressed
individual differences rather than differences related to asylum status, gender, origin or
psychopathology, the present QES could not compare and contrast the data set in relation to these
participants’ characteristics. For similar reasons the QES did not compare and contrast among the
different contexts in which primary studies were conducted. The following section presents the
analytical clusters and descriptive themes. Quotation marks are used to indicate expressions
obtained from primary studies.
66
Figure 5
Analytical clusters grouped according to the research questions.
Note. Clusters only mentioned by PSPs are depicted in italic.
Table 3
Analytical clusters, allocated descriptive themes and studies that contributed to each
A. What are positive/helpful aspects in the therapeutic process?
Cluster Descriptive Theme Evidence in Studies Patients

or PSPs
A1. Relationship as key & therapeutic in itself AR, MAI, MI, PU, SC, VA, VI, WA Both
Importance of trust MAJ, MI, PU, SC, VA, WA Both
Relationship for safety SC, WA PSPs
Empathy, warmth, care MI, VA, VI Both
Solidarity, belief, becoming a witness AR, MI, PU, VA, VI, WA Both
Support MAI, MI, PU, VA, VI Both
Respect MI, VA, VI Both
Flexible boundaries: Being like family or friends MI, SC, VA, VI Both
Psychoeducation - understanding one’s problem MAI, MAJ, MI, PU, SC, VI, WA Both
& the therapeutic process
A2. Focus on patient, situation & adapt the approach MAI, MI, PU, SC, VA, WA Both
Mindfulness of the refugee situation VA, WA Patients
Groups, especially for isolated patients PU, WA PSPs
Develop coping strategies MI, PU, WA PSPs
Integrative work SC, WA PSPs
Strengths based PU, SC PSPs
A3. Psycho-social Work MI, SC, VA Both
Empowerment PU, WA PSPs
67
PSP giving information on resettlement country MI, PU, SC PSPs

& skill training
Interdisciplinarity MI PSPs
Practical help & advocacy AR, MI, PU, SC, TH, VA, VI, WA Both
Direction and advice MI, VA, VI Patients
Hierachy of needs: Context = fundamental MI, SC, TH, VA, WA Both
feature of therapy
A4. Importance of supervision PU, SC PSPs
Importance of mentoring & networks PU, TH PSPs
Personal strategies to avoid getting overwhelmed PU, SC PSPs
by patients’ needs
A5. PSP having knowledge of & recognising the VA, WA Both
sociocultural environment of patients
PSP being curious & improving their cultural PU, SC, VA, WA Both
awareness
Working transculturally needs high sensitivity PU, SC, VA, WA Both
Learning from patients and mediators PU, SC, VA, WA Both
Work with mediators is helpful TH, VA Both
Talking about differences MI, PU, VA, WA Both
Reflecting on one’s own culture PU, TH, WA PSPs
B. What are negative/hindering aspects in the therapeutic process?
Cluster Descriptive Theme Evidence in Studies PSP or

Patients
B1. Difficult access to psychotherapy MAI, SC, VA, WA Both
Not enough time for therapy MI, TH PSPs
Lack of specialised supervision & networks SC, TH PSPs
Confusing & missing funding responsibilities SC, TH PSPs
B2. Post-migration difficulties enter the MAI, MAJ, MI, PU, SC, TH, VA, VI, Both
psychotherapeutic space WA
External instability hinders working on past SC, TH, VA, WA Both
Patients partly too dis-empowered to benefit MAI, PU, SC, TH, VI, WA Both
from MHS
PSPs feel overwhelmed & not competent due to PU, SC, WA PSPs
patients’ resettlement difficulties
PSP identify with patients’ hopelessness in their PU, SC, TH PSPs
current situation
PSP become frustrated & outraged by challenges PU, SC, TH PSPs
patients face in resettlement
Impacting: Separated families/isolation MI, VA, VI, WA Both
Impacting: Living & housing MAI, MI, VA, WA Both
Impacting: Job and economic situation TH, VA, WA Both
Impacting: Insecure asylum status, fear of MAI, MAJ, MI, PU, SC, TH, VI, WA Both
deportation & uncertainty of future
Impacting: Situation in country of origin MAI, MAJ, MI, SC, TH, VA Both
Impacting: Social exclusion & discrimination AR, MAI, VA Patients
B3. Bad or limited MHS in country of origin MAJ, VI Patients

Lack of information & transparency on MHS AR, MAJ Patients
Mistrust in profession & competence AR, MAJ, VA, VI Patients
MHS in a context of initial mistrust MAJ, VA, VI Patients
Lack of respect or invasiveness of PSPs AR, VA Patients
Stigma: “mentally ill” in some patients MAI, MAJ, PU, VA, VI Both
B4. Cultural differences as difficulty AR, MAJ, SC, TH, VA, VI, WA Both
Patients having different worldviews & concepts MAI, MAJ, MI, VI, WA Both
of mental health than PSP
68
Abstinence & neutrality do not work SC PSPs

PSP feel incompetent when what they learnt SC, TH PSPs
does not work with other cultures
Perceiving PSP as insensible towards cultural AR, VA Patients
differences & narrow minded
Language differences = difficulty PU, SC PSPs
PSPs perceive no synchrony with interpreters, MI, TH PSPs
under-/overinvolvement
Worry about incorrect translation VA Patients
C. What are ambivalent aspects in the therapeutic process?
Cluster Descriptive Theme Evidence in Studies Patients

or PSPs
C1. Letting things out & catharsis AR, MI, VA Patients
Structuring mental chaos through talking MAI, MI Both
Linking words, feelings & bodily sensation MI, VA Both
Reflecting on moral dilemmas MI PSPs
Talking = implicit prerequisite MHS MI, VA PSPs
Acting against cultural norms & customs when VA, WA Both
talking about intimate problems
Wanting to protect family by not talking VA, WA Both
Needing practical advice/medication, not talking MI Patients
C2. Negative consequences of accepting past traumas VI, WA Both

& potential re-traumatisation
Desire to avoid talking about past VI Patients
Addressing trauma is inappropriate in instability SC, TH, VA Both
Talking about trauma worsens pain MAJ, VA, VI Patients
Being forced to remember things you want to MAJ, VA, VI Patients
forget by narrating trauma
Constructing meaning MI, SC, VI Both
Creating continuity for fragmented memories & MI, SC PSPs
discontinuity of experience
Narrating & re-experiencing = part of the MI PSPs
healing
C3. No use of psychotherapy if context of patients MI, PU, SC, TH, VA, VI Both
remains difficult
Mixed experiences & thoughts about use PU, VA, VI Both
Psychotherapy did, does or will not help. AR, MAI, MAJ, MI, VA, VI Patients
Experiencing symptom improvement. AR, MAI, MAJ, VA, VI Patients
Appraisal of use of MHS mostly changing from MAI, PU, VA, VI Both
negative to positive
Regaining hope through therapy VA, VI Patients
C4. Loss and trauma as a major topics MAJ, SC, TH, VA, VI, WA Both
Ongoing violence in country of origin is TH PSPs
burdening for PSPs
Not getting a break from the topic PU PSPs
Heavy demands on PSP; feeling overwhelmed PU, SC, TH PSPs
Personal alteration processes of PSP SC PSPs
Vicarious traumatisation, burnout, worsening of PU, SC, TH PSPs
worldview
Adding meaning & awareness, mutual learning PU, SC, WA PSPs
Note. AR = Al-Roubaiy et al, 2017; MAI = Maier & Straub., 2011; MAJ = Majumber et al., 2015; MI = Mirdal et
al., 2012; PU = Puvimanasinghe et al., 2015; SC= Schweitzer et al., 2015; TH = Thöle et al., 2017; VA = Valibhoy
et al., 2017; VI = Vincent et al., 2013; WA = Warr, 2010.
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A. What are positive/helpful aspects in the therapeutic process?
A.1. A healing therapeutic relationship of trust, solidarity, respect and flexible boundaries
Therapists identified the therapeutic relationship as therapeutic in itself because an authentic, mutual
relationship afforded traumatised clients the opportunity to experience a sense of safety within the relational
dyad. (Schweitzer et al., 2015, p. 112)
In most of the studies, PSPs and patients both described the therapeutic relationship as key
to the experience of MHS and as being therapeutic in and of itself when it gave patients the feeling
of being understood through PSPs’ empathy, warmth, and care. Healing relationships involved, for
patients and PSPs, a sense of solidarity and belief in patients’ stories. For PSPs in two studies, a
healing therapeutic relationship included patients experiencing safety. Yet, patients rather stressed
the feeling of being respected as important. Some PSPs and patients characterised positive
relationships by a sense of “flexible boundaries”: Patients considered PSPs to be relatives or
friends. PSPs in two studies highlighted that classical boundaries of abstinence and distance were
not appropriate when working with refugee patients, which they explained by cultural reasons and
the demands of the post-migration refugee situation. Instead, they reported that it was helpful to
transcend relationship boundaries by following patients’ invitations to events outside of therapy or
by sharing personal information. This was considered a part of building trust and connecting across
cultural differences with patients. Trust was perceived as an essential element of a helpful
relationship in the majority of studies and by both, PSPs and patients. It was described to develop
through engagement from the PSP, which sometimes involved expanding the professional role and
advocating on behalf of patients (see Figure 6a).
A.2. An adaptive approach focusing on psychoeducation, coping and strengths
You really had to adapt what you were providing to understand that people didn’t come with one particular
issue. (Schweitzer et al., 2015, p. 113)
In six of the studies, PSPs and patients described that central to the therapy with refugees
is the adaptation of the approach to the needs of the refugee patients. For patients, PSPs who
listened to and assisted them with their practical needs were regarded as supportive, whereas PSPs
who stuck to “classic” therapeutic methods were criticised as not mindful of their situation. In that
regard, de-contextualised therapeutic advice, for example sleep related strategies, was considered
inappropriate. Patients and PSPs found it helpful when the latter listened to what each individual
patient brought into the therapeutic space and avoided “narrowness” and “pre-assumptions”. PSPs
in two studies found it beneficial to work integratively by drawing on multiple therapeutic
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perspectives. Also, a focus on the strengths of the patients was described as useful in two studies,
emphasising patients’ resilience regarding the obstacles they had overcome and were facing in
resettlement. PSPs in three studies saw it as helpful to develop coping strategies with their patients,
especially in group therapies. Creative therapies were also considered helpful as they offered
alternatives to MHS purely based on verbal expression. Patients rarely described specific
approaches. However, they highlighted how psychoeducation helped them to understand their own
difficulties. PSPs in all but one study mentioned psychoeducation as a central pillar in the
therapeutic process.
A.3. Context as a fundamental feature of psychotherapy highlighting the importance of psychosocial work,
empowerment, and advocacy
Many described the dual benefits of advocacy—both to empower clients and to build vital trust.
(Puvimanasinghe et al. , 2015, p. 13)
In half of the studies, patients and PSPs described a strong hierarchy of needs of refugees
in resettlement, making context work an essential feature of the MHS. In two studies, PSPs
explicitly stressed the concept of empowerment, which they saw as enabling refugees to overcome
their contextual difficulties. In eight studies, context work meant that helpful therapy aspects
included PSPs engaging in social work, advocating on behalf of their patients, and providing
practical help to meet patients’ resettlement needs. PSPs in one study described how this was
facilitated by working in interdisciplinary teams and networks consisting of social workers, lawyers,
etc. In this way, the diverse needs of patients could be addressed by various professions, the
perceived responsibility load for PSPs was reduced, and the extent to which PSPs needed to leave
their traditional professional role was limited.
A.4. Support structures and strategies for PSPs to avoid getting overwhelmed
…many acknowledged the vital function of supervision and mentoring. (Puvimanasinghe et al., 2015, p.
15)
This analytical cluster was only mentioned by and relevant to the PSPs. They described that
supervision, through which PSPs could receive support to reflect upon their professional role and
boundaries, as well as to mentoring, prevented them from getting overwhelmed by their patients’
needs, resettlement difficulties, and traumatic stories. In two studies, PSPs referred to personal
strategies to distance themselves emotionally from their patients’ situations and stressed the
importance of reducing their caseloads.
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A.5. Cultural sensitivity, mutual learning, and constant reflecting
Participants wanted practitioners to be ready to learn about and accommodate nuances in ethnic and
religious identities. (Valibhoy et al., 2016, p. 8)
In the majority of studies, patients and PSPs regarded high sensitivity for cultural
differences as essential (see Figure 6e), as the cultural background was seen to influence ideas about
mental health, psychotherapy, Western health care systems and patients’ self-images when seeking
MHS. Both groups thought it helpful if the PSPs constantly aimed at increasing their cultural
awareness, for instance by discussing differences with patients and interpreters. At the same time,
rather than PSPs having solid “knowledge” about other cultural contexts, patients and PSPs
stressed the importance of the PSP remaining open-minded, curious, and willing to learn from
patients. PSPs in three studies pointed to the necessity of being conscious about the fact that their
own cultural background, not only that of their patients, is brought into the therapeutic space. In
three studies, providing information on the resettlement culture was considered useful to help
patients adapt to their new environment.
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Figure 6
Relations between analytical clusters
6a 6b
6c 6d
6e
Note. Clusters only mentioned by PSPs are depicted in italic.
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B) What are negative/hindering aspects in the therapeutic process?
B.1. A context of lacking mental health care structures and funding
One weekly session is not enough. Persons who are so heavily affected need more… (Mirdal et al., 2012, p.
454)
Missing MHS structures were mentioned as a primary difficulty in six studies. Patients
complained about waiting lists and the difficult access to MHS. PSPs additionally referred to
tedious procedures to secure funding for the treatment of refugees or, in some cases, their
nonexistence. The financing of interpreters was reported to be especially difficult. PSPs described
how cancelled appointments placed them in dilemmas, as there were no structures to cover their
expenses. Furthermore, PSPs criticised the lack of appropriate supervision and networks of
support, which negatively affected their own well-being (see Figure 6b).
B.2. The constant threat to the external and internal stability of patients
… it’s very difficult to start working with clients unless they have already been given refugee status because
until the young person begins to feel secure and safe in their environment, it’s difficult to start dealing with
the issues. (Warr, 2010, p. 272)
This cluster includes the highest number of descriptive themes and involved all primary
studies. PSPs and patients depicted how the mental stability of patients is constantly threatened by
two main aspects – the difficulties in resettlement and the current situation in the country of origin.
These aspects seemed to enter the therapeutic space as a permanent source of worry for patients,
influencing their well-being, making it often inappropriate to address past traumas. Concerning
the first aspect, the difficulties in resettlement, a “hierarchy of needs” became apparent in which
improvements in the resettlement context of refugee patients seemed more urgent for their well-
being than psychotherapy. Resettlement stressors such as future insecurity, lack of a secure asylum
status, unemployment, social exclusion, and separation from families burdened patients but also
affected PSPs – the latter often did not feel competent to deal with the complexity of this situation
or became frustrated or hopeless regarding the existential challenges their patients had to face.
Patients saw it as a major difficulty when their PSPs were not aware of their refugee situation. In
six studies, the ongoing violence in the country of origin were also referred to as impacting patients’
well-being and the MHS, having the potential to undo what had been achieved in MHS at any time.
B.3. Mistrust in psychotherapy due to negative experiences, stigma and lacking transparency
...the recurrent experience of clients not being informed of their therapists’ educational backgrounds,
orientation in therapy, and/or treatment structure: ‘I did not know this idea that there are different methods
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used for different types of disturbances […] I actually learned afterwards towards the end of my counselling
with her. But she did not explain any of this to me.’ (Al-Roubaiy, 2017, p. 467)
This cluster exclusively related to the perspectives of patients. They saw the development
of trust as particularly difficult as atrocious experiences in the past, having been victims of
persecution, and inhuman treatment lead to the natural reaction of general distrust of other people
and particularly of those working in formal institutions (see Figure 6c). Current experiences in
resettlement countries such as a lack of transparency and social exclusion also contributed to
mistrust. Furthermore, patients in four studies reported mistrusting the whole profession of MHS,
on the one hand due to negative stigma of psychotherapy and mental illness. On the other hand,
the mistrust was also caused by a lack of information on MHS and insufficient transparency from
PSPs concerning their work. Some patients reported mistrusting the competence of their
practitioners, which was reinforced when the PSP appeared inquisitive or not mindful of their
refugee situation.
B.4. Diverging cultural and language backgrounds
…concerns were raised about interpreters omitting material, interpreting inaccurately, hampering
interpersonal dynamics, inserting opinions, or passing judgment on the client (Valibhoy et al., 2016, p. 8)
Building the therapeutic relationship was described as a challenge by patients and PSPs in
general. This was explained by several factors, mainly language and cultural differences and negative
prejudices against psychotherapy (see Figure 6d). The latter led some patients feeling like a failure
due to their problems and finding it difficult to be open to receiving support. The diverging cultural
backgrounds of patients and PSPs were also mentioned as a difficulty; PSPs framed this mostly as
“cultural differences in general,” which made bonding with patients more complex. Patients were
particularly critical about, and sensitive toward, their PSP’s position. In two studies, they felt PSPs
were judgmental or disrespectful regarding cultural differences, forcing their own values upon
them. They perceived PSPs as narrow-minded toward different ways of being and feeling. In most
cases, PSPs and patients spoke different languages, which made direct one-to-one communication
impossible. Therefore, PSPs worked with the support of interpreters. However, sometimes PSPs
and patients perceived a lack of synchrony between PSPs and interpreters or criticised interpreters’
over-involvement (e.g., independently asking questions) or underinvolvement (e.g., symbolising
disinterest via body language). Also, PSPs were preoccupied with interpreters’ well-being, especially
when it came to trauma work. Patients were particularly worried about interpreters changing the
content of what they said. These worries were described as impeding both the relationship building
and the therapeutic process.
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C) What are ambivalent aspects in the therapeutic process?
Some aspects of the MHS experience were found to be ambivalent either because the
findings of the studies contradicted each other, participants differed in their opinions among each
other, or participants experienced internal ambivalences regarding a particular aspect.
C.1. Talking: Acting against cultural norms vs. prerequisite of therapy
What I need is physical therapy and massage. I do not need to talk… (Mirdal et al., 2012, p. 454)
Talking in general was an ambivalent aspect of MHS. On the one hand, a number of
patients perceived it as helpful to “let things out,” structuring mental chaos through verbal
expression, and having someone who listened. Many PSPs saw talking as an implicit prerequisite
of MHS. On the other hand, patients in two studies felt that they were acting against cultural norms
that made the verbal expression of personal emotions inappropriate (see Figure 6e). Others feared
for the safety of their families and therefore felt uncomfortable when having to talk. In one study,
participants also questioned the benefit of talking – they did not perceive it as useful and rather
sought medication, physical therapy, or practical advice.
C.2. Trauma exposure: Creating continuity vs. suffering again
‘Someone is forcing you to talk about them and you, you are trying to forget them [...] you are forced to
remember, so you feel discouraged and you feel no happy, no happy. You feel angry at the time.’ (Vincent et
al., 2012, p. 584)
Trauma work was often discussed as an integral part of psychotherapy with refugees.
However, the results also show that it was not seen as the most important aspect, and often
considered appropriate only after patients’ situational improvements. It was predominantly PSPs
who considered narrating and re-experiencing traumatic memories as part of a healing process.
Many referred to the importance of creating continuity for fragmented memories by talking. Some
refugee patients perceived talking about traumas as helpful because it allowed them to give meaning
to their experiences. However, in three studies, patients held the opinion that narrating the past
might worsen the pain, they did not understand why they had to relive the suffering, or felt that it
countered their desire to forget. PSPs in one study also mentioned that trauma exposure comes
with the risk of re-traumatisation.
C.3. The use of psychotherapy: Regaining hope vs. not seeing its point
‘What is the use of spending so much money on my treatment if I am going to stay unemployed? I never see
anyone. I become ill if I don’t work.’ (Mirdal et al., 2012, p. 455)
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Another ambivalent point was the attributed benefit of MHS in itself. Many patients and
PSPs agreed that it was of no use if the resettlement situation remained difficult and characterised
by a constant fear of deportation (see Figure 6c). In six studies, several patients held the opinion
that MHS was unhelpful. However, for some patients, the uncertainty of their external situation
increased the value of MHS: It provided a stable space with a person from the majority population
listening to and supporting them. They appreciated being helped to deal with their stress and
described how they regained hope, and experienced symptom improvements. If the latter was the
case, in four studies, patients’ appraisals of the use of MHS changed from negative to positive over
time. PSPs also reported positive developments that made them see a usefulness in their work,
although many highlighted that patients’ basic needs had to be addressed first.
C.4. Impacts on PSPs: Adding meaning vs. vicarious traumatisation
All of the participants described some awareness of personal changes that resulted from their work with
refugee clients. (Schweitzer, 2015, p. 114)
This final cluster exclusively concerns PSPs and their well-being. PSPs experienced the
MHS with refugees as placing heavy demands on them. They described how the work with refugee
patients involves listening to many atrocious experiences, stories of trauma and loss –patients losing
family, their home, and cultural frame of reference. Compounding this, patients’ harsh experiences
do not lie exclusively in the past but are rather ongoing due to the resettlement difficulties and the
continuation of violence in the countries of origin. Consequently, some PSPs reported getting
overwhelmed by patients’ stories, and becoming frustrated with their own home country. In three
studies, PSPs saw the worsening of one’s world view, vicarious traumatisation, and burnout as
consequences. The risk for such negative consequences was augmented by assuming excessive
responsibility for patients’ needs, by seemingly being the only significant person for the patient in
the resettlement context or by keeping relationship boundaries flexible which yielded the potential
of PSPs overly identifying with patients (see Figure 6a). However, PSPs’ transformative experiences
were not exclusively negative. Positive consequences were described in three studies such as
becoming aware of their own privileges, being inspired by their patients’ strength, and obtaining a
sense of meaning from their work.
Discussion
The present article synthesised 10 qualitative studies investigating PSPs’ and refugee
patients’ perspectives on MHS. We could confirm many of the findings by Karageorge et al. (2017),
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even though our analysis was based on entirely distinct primary studies. In the following section,
the central findings will be linked to the scientific literature and their implications will be discussed.
Consistent with ample research, this QES shows that the external context of refugee
patients highly influences the MHS, which relates to missing mental health care structures for
refugee patients (De Anstiss et al., 2009; Kluge, 2016; Knobloch, 2015) and notably to the effect
of the resettlement situation on patients’ well-being (Beiser, 2009; Bhugra, 2004; Hassan et al.,
2016). The latter might call the use of psychotherapy into question as long as patients remain in a
situation characterised by disempowerment and unclear asylum status (Codrington et al., 2011;
Savic et al., 2016; Summerfield, 1999; Watters, 2001). At the same time, the difficult resettlement
context might increase the importance of MHS as a stabilising factor (Kronsteiner, 2017). Indeed,
many refugee patients experienced the therapy as a valuable safe space amid the external instability,
whereby engaging in psycho-social and interdisciplinary work, and advocacy seemed especially
helpful (Goodkind et al., 2014; Hassan et al., 2016; Karageorge et al., 2017; Kramer, 2005).
Interestingly, the latter came up in studies that included various MHS professions as well as in the
ones that exclusively interviewed psychotherapists. Practical help and advocacy seem to be
beneficial due to their direct consequences, but also in an indirect way by supporting the
development of trust (Kronsteiner, 2017; Watters, 2001). This aspect is of central importance, as a
trusting therapeutic relationship was found to be a key to the MHS experience (Hassan et al., 2016;
Sandhu et al., 2013). Karageorge et al. (2017) do not explicitly report on healing impacts of a
therapeutic relationship in itself. However, the authors describe that “mutual understanding” is
central, but hindered by mistrust. This is consistent with the finding of the present study as well as
of others (Codrington et al., 2011; Sandhu et al., 2013; Turner, 1995) that establishing trust with
refugee patients might take a long time, as negative past experiences, unfamiliarity with the
resettlement country’s health care system, negative preconceptions of psychotherapy, and the
sometimes hostile attitudes of receiving communities are major barriers for the development of
trust.
Alongside trust, this QES found a healing relationship to be characterised by empathy,
respect, solidarity, and furthermore described as one of kin- or friendship and “flexible
boundaries”. Flexible boundaries remain a scientifically debated issue, and the present study
supports the view that they constitute a balancing act for therapists; they can strengthen bonds and
be appropriate especially for culturally competent practise (Speight, 2012; Zur, 2004). However,
they might counteract the goal of nurturing patients’ independence (Codrington et al., 2011) and
they come with the risk of PSPs overly identifying with patients (Kronsteiner, 2017).
In line with Karageorge et al. (2017), as well as Barrington and Shakespeare-Finch (2013,
2014), this QES found that working with refugees can have a deep impact on PSPs – positively by
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evoking inspiration and adding meaning, but also negatively by leading to frustration or vicarious
traumatisation. Therefore, it becomes vitally important that PSPs develop personal strategies for
distancing themselves and that they receive appropriate structural support, namely through
supervision and mentoring (Barrington & Shakespeare-Finch, 2013, 2014).
In terms of therapeutic approaches, this study and others (Codrington et al., 2011; De
Anstiss et al., 2009; Guregård & Seikkula, 2014; Savic et al., 2016) have found that the adaptation
of methods according to patients’ individual needs is central. Important pillars to such an adaptive
approach seem to be psychoeducation and transparency. Known to be of importance for general
patients as common factors across therapeutic schools (Wampold & Imel, 2015), these elements
become crucial for refugee patients, as the latter often face a lack of transparency and information
in resettlement countries (Davidson et al., 2008; De Anstiss et al., 2009; Sandhu et al., 2013).
Psychoeducation and transparency as central pillars can provide ways to establish trust, counter
disempowerment and stigma, and change patients’ potentially negative self-views when attending
therapy (Murray et al., 2010; Turner, 1995).
Cultural differences were described as a difficulty by patients and PSPs. At the same time,
as reported by Chang & Berk (2009) and Karageorge et al. (2017), asking questions and talking
about cultural differences were seen as ways to overcome the difficulties, as well as PSPs reflecting
on their own culture (Kirmayer, 2012b; Rober & De Haene, 2014) and involving interpreters
(Martins- Borges & Pocreau, 2009; Pugh & Vetere, 2009). Similar to Karageorge et al. (2017), this
QES found that, while PSP’s culture-specific knowledge is evaluated positively by patients, of
higher importance seems to be firstly, a willingness to learn from each other, and secondly, the
recognition of the socio-political context of refugees (Goodkind et al., 2014; Kluge, 2016; Kramer,
2005; Murray et al., 2010).
Finally, the present QES as well as Karageorge et al. (2017) found ambivalent attitudes
toward verbal therapies and narrating traumatic experiences which might also be due to the fact
that in some cultural contexts, talking about individual problems is regarded as inappropriate
(Ahearn, 2000a; Patel, 2003b; Savic et al., 2016). These ambivalences call for a careful consideration
of how appropriate trauma exposure approaches are for some patients, as people from different
backgrounds might have different “functioning” strategies to overcome painful experiences
(Becker, 2014; Reddemann & Sachsse, 1997). It remains open to debate whether a familiarisation
of patients with talking about their emotions is a necessary condition for therapy, or whether
alternatives could be taken into account such as empowering community-focused interventions
(Goodkind et al., 2014; Westoby, 2008), or creative therapies (Koch & Weidinger-von-der-Recke,
2009).
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Methodological considerations
There are several limitations to the present findings. Firstly, some might argue that
qualitative findings are not generalisable but rather specific to a certain context (Thomas & Harden,
2008). Meanwhile, others state that qualitative research will reach its full contribution only if
syntheses generalise across the increasing amount of individual studies (Britten et al., 2002).
Certainly, the findings of this QES represent the interpretation of the primary studies from the
perspective of the QES researchers. However, this study does not claim objectivity; it is rather an
attempt at a “subjective testimonial to other people’s voices” (Ahearn, 2000b, p. 15). During the
research process, steps were undertaken to ensure its transparency and enable its repetition
(Paterson et al., 2001; Tong et al., 2012).
Secondly, critiques may relate to the present QES’ inclusion of studies with adult and
adolescent patients, as well as the inclusion of a diversity of MHS professions rather than purely
psychotherapists. Yet, as the qualitative literature on the topic from insider perspectives is sparse,
our aggregation seemed appropriate to obtain a broader database. Meanwhile, attention was given
to the potential impact of the difference in participants when analysing the material. Furthermore,
the present study included the perspectives of 23 asylum-seekers and 54 refugees, but the database
did not allow for an investigation of differences in relation to asylum status. Asylum-seekers, unlike
refugees, do not yet have a clear status in the host country, but rather still wait for their claim to be
processed. Thus, their status is uncertain and temporal and they often fear deportation which has
been described to highly influence their mental health (Momartin et al., 2006). This QES found
that clients’ insecurities about their future were stressed in most of the primary studies
independently if the sample included asylum-seekers and/or refugees, but due to the restricted
information no clear conclusions could be drawn. Certainly, more studies are needed to understand
in which way asylum status as well as other patients’ characteristics might impact the therapeutic
relationship and process. Similarly, limited contextual data provided in primary studies did not
allow for a comparison among different contexts of resettlement and reception of patients,
although these contexts play an important role for MHS and refugee mental health. Restricted
information on participants and contexts provided by primary studies is an issue for qualitative
evidence synthesis that has been noted critically by others (Paterson et al., 2001; Thomas & Harden,
2008).
Thirdly, including only primary studies with a single methodology in the synthesis might
have been limiting as triangulation of diverse methods can help to counter the limitations of one
method with the strength of another. However, there is a debate around the appropriateness of
mixing different qualitative methodologies in a synthesis (Booth, 2016; Jensen & Allen, 1996), as
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problems in comparability might arise from incongruencies between the underlying epistemologies
of methods (Jensen & Allen, 1996).
Finally, the synthesis did not achieve its initial goal of including studies from non-Western
countries. Despite using Ibero-American and francophone databases, as well as key words in five
different languages, the final selection of studies stems exclusively from Western countries. There
are two likely explanations for this. Firstly, the selection criteria of the present QES might have
given preference to a Western way of conducting research and not allowed different ways of
generating knowledge to enter the analysis. Secondly, there seems to be little research on the topic
of mental health support for refugees in non-Western countries (Teixeira et al., 2013).
Conclusion and Recommendations for Practice and Future

Research
In terms of implications for practice, this QES suggests that the greatest emphasis in the
MHS with refugees should be given to the development of a trusting relationship between the
professional and the patient. The challenge for the PSP might be to remain open-minded and
flexible in terms of relationship boundaries and in terms of adapting to patients’ needs, increasing
one’s cultural sensibility and awareness of the refugee context. Working in interdisciplinary
networks, using integrative therapy approaches, and receiving appropriate structural support might
help to meet these challenges and encounter the risk of overly burdening PSPs. Furthermore,
psychoeducation and transparency are important for enabling patients to make their own decisions
and develop trusting relationships. Future research might investigate in more detail the
development of trust. In doing so, particular attention should be paid to providing sufficient
contextual information on participants, their asylum status as well as the policies of refugee
reception in the study’s country of origin. Also, further studies investigating refugee patients’
perspectives could shed more light on the meaning of trauma exposure approaches for those who
experience them. In terms of policy development, the present study provides further evidence for
the fact that context improvements are central to refugees’ mental health. If the aim is to foster
refugees’ well-being, the first step should be to improve their life situation by facilitating asylum
procedures and family unity and quickly providing work permits.
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Chapter 3
Challenges to Qualitative Evidence Synthesis
– Aiming for Diversity and Abstraction
Without Losing Meaning
Gesa Solveig Duden
Submitted to Methods in Psychology

Section I | Chapter 3 Methodological Thoughts on QES
Abstract
Recent years have seen an increase in the publication of qualitative studies in psychological
research. As meta-analyses in quantitative research, qualitative evidence synthesis (QES) methods
such as meta synthesis, thematic synthesis, or meta ethnography aim to aggregate and analyse
findings from qualitative inquiries. However, these approaches are still largely unknown to
psychological researchers and come with a number of challenges. The present article aims to
introduce QES to the reader and outline some of the benefits of this meta approach to qualitative
studies. In particular, the objective is to shed light on two challenges of QES: on the question of
how to include studies from a great diversity of countries and cultures, and on the conflict of
reducing, merging, and abstracting from the findings of primary studies while aiming to preserve
their full contribution and meaning. These challenges are explained by providing a practical
example of a qualitative evidence synthesis from the field of mental healthcare research. The article
concludes with some suggestions for future qualitative meta researchers such as those working in
teams that include members from a plurality of contexts who speak a multiplicity of languages, as
well as transparently reporting on decisions taken during the research process.
Keywords: Qualitative Evidence Synthesis, Thematic Synthesis, Meta Synthesis, Qualitative Meta-
Analysis, Decolonising Research, Intellectual Style
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Introduction
In recent years, qualitative approaches have gained more prominence in psychological
research, and the polarisation between quantitative and qualitative methods seems to have reclined
(Barbour & Barbour, 2003; Wertz, 2014). An increase in individual qualitative studies (Kazak,
2008), however, makes it necessary for researchers to engage in meta procedures that aim to review
and synthesise the findings of primary studies (Paterson et al., 2001). Such procedures can allow
the researcher to gain overviews about the state of the art in a specific field and insights into
concurrent and contrasting human experiences across qualitative studies. Synthesis methods have
already been developed and used since the late 1980s, but they seem to be poorly known among
psychological researchers (Timulak, 2007, 2009). In the context of health technology assessments
and clinical trials, Booth et al. (2016) suggested the label “qualitative evidence synthesis” (QES) as
an umbrella term referring to the various methods that have been described as tools to synthesise
qualitative studies on a meta level. QES treats individual primary studies as data for analysis with
the objective to classify, extract, and integrate differences and similarities in the primary studies to
create a higher-order synthesis.
The following article briefly introduces methods for synthesis of qualitative studies but does
not provide a guideline or framework for conducting QES, since this can be found elsewhere (e.g.,
Finfgeld-Connett, 2008; Lockwood et al., 2014; Paterson et al., 2001; Thomas & Harden, 2008;
Timulak, 2009; Tong et al., 2012). Instead, the main objective of the present article is to shed light
on two major challenges which I, a researcher in cultural-clinical psychology (Ryder et al., 2011),
encountered when conducting QES. Firstly, there was the question of how to conduct a synthesis
that includes findings from a diversity of countries and contexts while, as a researcher from a very
specific academic culture, I was used to a very specific way of conducting and evaluating research.
Secondly, there was the problem of aiming to condense and abstract from primary studies, whilst
at the same time wishing to maintain the meaning, complexity, and context of their findings.
Working on a meta level

QES serves the function of translating, integrating, and transferring findings from
individual qualitative primary studies to answer research questions (Booth et al., 2016). Using QES
means working on a meta-level of research. The term “meta” derives from the Greek preposition
“μετά”, which means “changed”, “with”, or “after” (Harper, 2020), but it has come to be used
most commonly to refer to a secondary or higher level of abstraction, to something that
“transcends” a concept, such as in the case of “meta-communication”, which is a secondary form
of communication analysing or underlying the primary communication (Harper, 2020). The term
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“meta” has reached many scientific realms such as mathematics and computational sciences (e.g.
“meta-optimization”), engineering (e.g. “meta-process modelling”), and statistics (e.g. “meta-
analysis”). The present article refers to the meta level without relating to any specific method (such
as the meta-study of Paterson et al., 2001), but rather in order to differentiate between the level of
primary studies and a higher-order, meta investigation.
In quantitative research, meta-analysis is a procedure now widely known in psychology
(Schmidt, 1992). It refers to the secondary quantitative and statistical evaluation, investigation, and
integration of the results of a large number of quantitative primary studies (Schmidt, 1992). Already
in 1992, Schmidt stated that the use of meta-analysis has helped to demonstrate that there is
very little information in any single study and that, in contrast to what is often assumed, no
primary study can solve a research problem completely on its own. Since then, meta-analyses
have come to be valued as one potential means to overcome the “reproducibility crisis” of the
psychological sciences. They call attention to the lack of transparent research practices, p-hacking,
publication bias, and other meta-scientific problems in psychology (Nosek et al., 2015; Polanin et
al., 2020). Meta-analyses increase the numbers of observations or sample sizes and therefore the
statistical power of findings. They can also serve as a way to resolve inconsistencies across studies,
and to identify moderating or mediating variables (Stone & Rosopa, 2017). There are plenty of
examples of such meta-analyses in the psychological sciences, and particularly in psychotherapeutic
research—as early as 1977, Smith and Glass compared groups undergoing psychotherapy and
counselling to control groups to estimate the psychotherapeutic effect (Smith & Glass, 1977).
According to Wampold and Imel (2013), the number of meta-analyses in psychotherapy research
has expanded enormously in the beginning of the 21st century, leading to 51 meta-analytical
publications in the field in 2011 alone.
Meanwhile, meta-analyses are limited to the secondary investigation of primary quantitative
studies. Increasingly it has become accepted that a more comprehensive understanding of
psychological issues requires a greater variety in methods integrating qualitative inquiry and
triangulation (Barbour & Barbour, 2003; Donald & Carey, 2017, Malterud, 2001b, McLeod, 2001,
Wertz, 2014). In the realm of psychotherapy research in particular, which is the context of the
exemplary study of this article, that will be discussed later on, the main focus has been quantitative
studies investigating efficacy issues of psychotherapy approaches (e.g. Benish et al., 2008).
Quantitative studies, however, may alone not be well suited to disentangle how psychotherapy is
effective, as qualitative differences in treatment, for instance, can remain hidden beneath
quantitatively equivalent results (Donald & Carey, 2017). Diverse authors have stressed that
psychotherapy research should not purely focus on quantitative outcomes and efficacy of treatment
strategies but include investigations on the processes that take place in psychotherapy and the
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subjective experience of those involved in the therapeutic space, namely therapists and clients
(Duden & Martins-Borges, 2020; Barrington & Shakespeare-Finch; 2014; Donald & Carey, 2017;
Guba & Lincoln, 1994; Levitt et al., 2016; McLeod, 2011; Whitley, 2012). As a response, a growing
number of qualitative studies have indeed focused on the perspectives of patients and professionals
(e.g. Barrington & Shakespeare-Finch, 2014; Chang & Berk, 2009; Pugh & Vetere, 2009; Shearing
et al., 2011). While it is encouraging to witness a move away from the higher value given to
quantitative research in the anglophone academic field, research projects are needed that aim,
similarly to meta-analysis in quantitative research, at structuring, integrating, and synthesising the
finding of primary qualitative studies on a meta level (Duden et al., 2020; Levitt et al., 2016; Noblit,
2018; Paterson et al., 2001).
QES, Systematic Reviews, and Secondary Analysis

So, what distinguishes qualitative evidence syntheses from traditional systematic literature
reviews? Both approaches aim to provide an overview of the often numerous single primary studies
that exist in a field. Both approaches undertake an investigation of the literature according to a
rigorous, transparent, and explicit method (Brunton, 2020; Greenhalgh et al., 2005). Systematic
reviews of qualitative research have increased in number since the late 1980s (Finfgeld-Connett,
2014). They have come to be preferred over traditional literature because they are perceived as
more comprehensive, replicable, and objective (Weed, 2005). The aim of systematic reviews is to
aggregate the “best evidence” (Cook et al., 1997; Dixon-Woods et al., 2006) using an explicit process,
to test theories, and to investigate, in particular, the question of “what works” (Dixon-Woods et
al., 2006). Systematic reviews are thus valuable to assemble, pool, and obtain an aggregation,
evaluation, and summary of primary studies. In contrast to this, the objective of QES is an
interpretation and generation of theory, based on the primary studies. Researchers conducting QES,
i.e. meta-investigations in the qualitative realm, are, instead of purely aggregating studies, working
on a third level of abstraction (third-order interpretations, see Heyman, 2009) or what Weed (2005)
calls a “triple hermeneutic”, as
• research participants interpret their experience (first order),
• primary researchers interpret the experience of participants (second order), and
• meta-synthesists interpret the interpretation of the interpretation (third order).
Noblit and Hare (1988) commented on the difference between “aggregative” and
“interpretative” work, which, for many, has come to be known as the main difference between
systematic reviews and qualitative evidence synthesis (Booth, 2016; Dixon-Woods et al., 2006). The
“meta” in QES such as meta-synthesis stands for “going beyond” the primary study, i.e. not
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summarising their results but “translating” them into one another in order to generate new findings
(Thomas & Harden, 2008). Translation in this context means taking a result, concept, or theme
from one primary study and recognising the equivalent result, concept, or theme in a different
primary study even when it is described and expressed with different words (Thomas & Harden,
2008). In that, the key function of QES is “synergistic” (Weed, 2005, p. 18), i.e. it leads to “insights
that are more than the sum of its parts”. Therefore, in the context of thematic analysis for
intervention studies, Thomas and Harden (2008) stated that “We do not find our recommendations
for interventions contained in the findings of the primary studies: these were new propositions
generated by the reviewers in the light of the synthesis” (Thomas & Harden, 2008, p. 9).
QES is, furthermore, not to be confused with secondary analysis, a somewhat related
approach as it is also concerned with a higher level of analytic abstraction. However, secondary
analysis refers to the reuse of primary original material (Corti et al., 2005). QES, in contrast,
synthesises the result sections (and sometimes methods and discussion) generated by the
researchers of primary studies (including the primary researcher’s interpretations and conclusions),
without any use of the original data sets (Weed, 2005).
Approaches and Use of QES in (Psychological) Research
Use of QES
QES has been used particularly in nursing research and the health sciences to inform health
and healthcare-related practice and policy (Barnett-Page & Thomas, 2009; Noblit, 2018). In the
psychological sciences, the use of QES is relatively new (Timulak, 2007, 2009); however, in the
field of counselling and psychotherapy research the synthesis of qualitative studies is slowly
becoming more common. For instance, Berry and Hayward (2001) conducted a qualitative
synthesis of users’ perspectives on cognitive behavioural therapy for psychosis, and Timulak (2007)
conducted a qualitative meta-analysis concerned with clients’ identifications of the impact of
helpful events in psychotherapy. More recently, Levitt et al. (2016) published a qualitative meta-
analysis on clients’ experiences within adult individual psychotherapy, Hill et al. (2018) a qualitative
meta-analysis on immediacy and the self-disclosure of therapists, and Katsakou and Pistrang (2018)
a meta-synthesis on clients’ experiences of treatment and recovery in borderline personality
disorder. Finally, along with colleagues I published a QES study in the field of transcultural
psychotherapy with refugees, focusing on the experiences of patients and professionals (Duden &
Martins-Borges, 2020). The present article emerges as a reflection on some of the major challenges
we encountered in the process of conducting a QES study ourselves.
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Approaches to QES
One of the earliest published works about methods for synthesising qualitative research is
from Noblit and Hare, who “in the midst of the qualitative-quantitative paradigm wars” in the
1980s described the approach of “meta-ethnography” (Noblit, 2018, p. 35; Noblit & Hare, 1988).
Meta-ethnography is now well established in health research (Noblit, 2018). It aims at a
reinterpretation and mid-level theory generation (Lockwood et al., 2015) and is characterised by
“metaphoric translation”, i.e. a process of translating studies into one another, which can be
refutational (the studies’ findings contradict one another), reciprocal (the direct translation of
studies into one another is possible), and/or line of argument (the primary studies tend to overlap;
however, when compared in more detail, it becomes apparent that the investigations address
diverging aspects of a larger explanation; Banning, 2003; Noblit, 2018; Noblit & Hare, 1988; Weed,
2005). An extensive explanation of the meta-ethnography approach can be found elsewhere (e.g.
Noblit, 2018; Weed, 2005). Since this first description of a meta-approach aiming to synthesise
qualitative research, a wide range of QES methods have been developed and used, especially in the
field of health research (Booth et al., 2016). Many of these methods draw on meta-ethnology and
make reference to this work (Thomas & Harden, 2008; Tong et al., 2012). There are at least 15
available approaches published in the scientific literature (Lockwood et al., 2015), such as for
instance the meta-study (Paterson et al., 2001), meta-aggregation (e.g. Lockwood et al., 2015),
critical interpretive synthesis (Dixon-Woods et al., 2006), thematic synthesis (Thomas & Harden,
2008), framework synthesis (Brunton et al., 2020), ecological triangulation (Banning, 2003), textual
narrative synthesis (Lucas et al., 2007), and meta-narrative (Greenhalgh et al., 2005). The diverse
approaches differ in their underpinning paradigms and theoretical orientation (e.g. objective
idealism, critical realist), their extensiveness, their way of identifying studies and analysing the data,
the use of quality assessment, and the way they problematise the literature or not. An overview of
the various methods, the epistemology they are based upon, their principal aim, and diverse
additional differences among approaches is provided by Barnett-Page and Thomas (2009). A good
introduction to different QES methods can also be found in the article by Booth et al. (2016).
In our own work, my colleagues and I have chosen to orientate our QES towards the meta-
study method (Paterson et al., 2001) and thematic synthesis (Thomas & Harden, 2008). The meta-
study method was selected for our study because its constructivist epistemology is in line with primary
research that focuses on insiders’ perspectives. This type of primary research is interested in the in-
depth knowledge constructions of individuals, called “insiders”. As the aim of our study was to
investigate the perceptions and experiences of mental health professionals and refugee patients,
our focus was on primary studies, following a constructivist insiders’ perspectives approach. The
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use of Paterson et al.’s (2001) meta-study method thus allowed for a compatibility in epistemology
and avoided violating the integrity or philosophical basis of the primary studies (Booth et al., 2016).
Therefore, Paterson et al.’s (2001) description of the method was taken as a practical guideline
during the data collection process. Meanwhile, thematic synthesis guided our analytical process, as we
were already familiar with thematic analysis. Thematic analysis is an analytical procedure for primary
research which provides the basis for the thematic synthesis method (Thomas & Harden, 2008).
The method leans towards a critical realist epistemology but is a quite flexible method and can be
used across a wide range of epistemological positions (Braun & Clarke, 2006). Thematic synthesis
was also suitable for our purposes as it focuses on the inclusion of a narrow range of methodologies
in primary studies (Booth, 2016), and we had only identified interview studies as primary data. The
analytical process includes stages of coding data from the results sections of multiple primary
studies, and of generating and interpreting the recurring themes (Thomas & Harden, 2008).
Benefits and Challenges in Conducting QES

Qualitative evidence syntheses can provide possibilities to access and learn about a variety
of in-depth experiences, perspectives, and meanings of human beings across diverse contexts
(Tong et al., 2012). The integration of findings from primary studies addresses one of “the main
weaknesses of qualitative methodologies” (Heyman, 2009, p. 1576), that is the generation of
increasing numbers of individual studies. There seems to be a general concern in the social sciences
that not enough use is being made of already existing research (Weed, 2005). QES can be a means
to overcome this problem. In the health sciences, QES has come to be valued, for instance, as an
approach to health technology assessment which is focused on the perspectives of users, clients,
or patients (Booth et al., 2018).
For psychology, QES may be a very useful approach to understand the processes and
mechanisms by which treatment interventions achieve their effects, for example (Booth, 2016).
QES may help to bring forward the generation of conceptual and theoretical models based on the
individuals’ experiences of psychological processes and phenomena across a diversity of contexts
(Tong et al., 2012). The approach can use and restate already published results, but moreover it can
serve to produce new ideas, theories, and propositions, as well as to identify research gaps.
Meanwhile, there are a number of contentious issues around QES that have been debated in the
scientific literature. These concern for instance the data retrieval process, the use of quality
assessment of primary studies, decisions on what counts as data, and the question of an inclusion
of primary studies with diverse methods (Finfgeld-Connett, 2014; Paterson et al., 2001;
Sandelowski et al., 1997, Tong et al., 2012). As these issues have been discussed elsewhere at length,
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I will not outline them here. The interested reader may refer to the publications by Heyman (2009),
Newton et al. (2012), Thomas and Harden (2008), Paterson et al. 2001, and Sandelowski et al.
(1997).
Instead, I will discuss two new issues our team found particularly difficult in the process of
conducting a QES study. Firstly, I will outline the challenge of trying to include primary studies
from a great variety of countries, published in diverse languages. Secondly, I will describe a tension
arising from the aim of bringing together, integrating, and merging data while trying to maintain
the depth and meaning of the primary researchers’ accounts of participants’ experiences.
Is another knowledge possible? On attempting to include non-anglophone

research and research from the Global South
A first challenge I want to discuss concerns the issue of how to include research findings
from a great variety of contexts and countries into a QES project. The dominance of published
investigations from Western countries (in particular from the US) and of investigations involving
Western samples only has been influencing psychological sciences and realities globally, but it is
increasingly receiving criticism (Adair et al., 2002; Henrich et al., 2010; Moghaddam, 1987). For
instance, Arnett (2008) showed that 95% of the research published in the six top journals of the
American Psychological Association (APA) had been conducted on European or Usonian17
samples, even though the WEIRD population (Western, Educated, Industrialized, Rich, and
Democratic) appears to be among the least representative samples available for generalizing about
human beings (Hartmann et al., 2013; Henrich et al., 2010). Many authors have called for a
heightened awareness that cultural contexts influence intellectual thought and affect how science
and research are conceived, carried out, interpreted, and evaluated (e.g. Ahearn, 2000b; Kirmayer,
2007; Summerfield, 1999, 2008). For instance, in the field of psychotherapy and psychopathology,
it has been argued that the explanatory models from Western countries tend to locate the cause
and responsibility for psychological suffering within the individual. Furthermore, the concept of a
person among Western researchers tends to reflect the idea of a self-contained unit, an individual
who is independent of others, agentic, and rationalistic (Ahearn, 2000b; Kirmayer, 2007;
Summerfield, 1999, 2008). Consequentially, Western psychotherapies tend to put more weight on
fostering autonomy than belonging (Guzder, 2014). This may not be an issue in and of itself;
17Usonian is a term coined by the architect Frank Lloyd Wright and the adjectival form for the people or things of the
US. It is deployed here because there are 35 different countries in the Americas, as well as a number of dependent
territories, and using the adjective American to refer to people from the US can be considered as possessive of the
Americas overall and is offensive to many Latin Americans.
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however, it becomes problematic when a certain view, such as the view of the individual, agentic,
and rationalistic self, or other cultural conceptualisations, are naturalised and taken for granted,
implicitly influencing research practice and findings and exported as “universal truths”.
International health, for example, has seen a framing mostly from a Western biomedical service
perspective, even though it has been widely argued that Western evidence-based medical practices
may not be equally effective, feasible, or culturally appropriate in other countries and cultures
(Kirmayer & Pedersen, 2006). In particular, the export of Western psychiatric classification and
diagnosis systems, such as the DSM-5, into other contexts has received criticism, as it may not be
applicable in all cultures. In fact, psychological distress and suffering may be conceived in very
diverse manners cross-culturally (Apostilodou, 2016; Summerfield, 1999; Warelow & Holmes,
2011; Westoby & Ingamells, 2010).
Fostering plurality and diversity in QES

The issue of a dominance of the Western perspective in the psychological sciences and the
associated problematic consequences for research, knowledge generation, and practice is not
particularly new, and it is increasingly being addressed (Adair et al., 2002; Arnett, 2008; Hartmann
et al., 2013; Henrich et al., 2010; Moghaddam, 1987; Summerfield, 2008). Meanwhile, and as to my
knowledge, in meta-research, including in reflections on qualitative evidence synthesis, questions
such as how to overcome this Western dominance and biases have not yet been approached.
In the QES study we conducted, our aim was to include qualitative studies and findings
from a wide range of countries. We wanted to not only look at the situation of mental health
support for refugees in Western settings, but also to take into consideration the experiences of
refugee patients and professionals in diverse contexts, countries, and realities. However, soon we
encountered our own limitations, the first being language skills. In order to find studies, we had to
conduct an extensive search—we managed to use keyword search in five different languages,
allowing us access to English, German, French, Spanish, and Portuguese publications. Meanwhile,
using “only” five languages, of course, left many potentially relevant studies undiscovered that may
have been published in any other language. In psychological research there tends to be a prevailing
assumption that research findings are generally published and communicated in English, and there
certainly is a bias in research favouring native English-speaking authors (Salager-Meyer, 2008).
However, in fact, in many non-Anglophone countries, such as Brazil, France, and Germany, there
is a large body of scientific literature published in the countries’ official languages (Van Leeuwen
et al., 2001). Thus, we have to assume that there may be much to discover scientifically in other
languages. If one would speak more languages, one may have access to research findings from a
greater variety of contexts. As Wittgenstein (1973, Tractatus logico-philosophicus, sentence 5.6) noted,
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“The limits of my language mean the limits of my world”. Thus, a first recommendation for meta-scientists
is to work in teams of researchers who together speak a multiplicity of languages.
The second issue arose from the question of where to find studies. In general, in QES a
plurality of methods for retrieval of primary studies is recommended: keyword search in scientific
databases and hand-searching of relevant journals, citation tracking, and contacting experts in the
field (Booth, 2016). We conducted our search across several international databases: Web of
Science, PsycINFO, EBSCO, Psyndex, Repère, and Redalyc. The first three are mainly English
language-based databases. Psyndex is a database used in German-speaking countries, while Repère
primarily presents articles from francophone countries and Redalyc articles from Ibero-America
(see Duden et al., 2020). Our research team included Brazilian researchers who were familiar with
the latter two databases. Studies from Latin America, for instance, are more easily located in
Redalyc than in any of the psychological databases commonly used in the anglophone world. The
non-Brazilian members of our team had not been aware of these databases.
Table 4
Databases, language of keywords and hits
Language English French German Portuguese Spanish Sum
Flucht* OR
Réfugié* OR Asyl* AND refug* OR
refuge* OR Asyl* AND Psychotherapie asilo E
asylum AND psychothérapi OR Psycho- refug* OR asilo psicoterapia*
psychothera e OR santé soziale E psicoterapia* OR
py OR mentale OR Versorgung OR OR intervenção intervención
mental healh intervention psychische OR acolhimento OR asesoría
OR counsel* OR psycho* Gesundheit OR saúde OR salud
AND AND AND mental AND mental AND
qualitative qualitati* OR Qualitativ* OR qualitativ* OR qualitativ* OR
Keywords OR interview interview Interview entrevista entrevista
Web of
Science 74 0 0 0 0 4
Psyc info 98 0 35 0 0 33
EBSCO 103 7 13 9 12 44
Redalyc 28 75 0 56 102 61
REPERE 0 67 0 0 0 7
Psyndex 0 0 6 0 0 0
Sum 303 149 54 65 114 85
Therefore, it is likely that internationally there is a great number of other databases which
our team did not know and which would have allowed for an easier identification of studies from
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diverse countries. Thus, already our search strategy yielded results from only a limited number of
countries. Table 4 shows the total number of keyword hits in each language and each database. We
identified 685 studies in total, of which 303 were English, 149 French, 114 Spanish, 65 Portuguese,
and 54 German language publications. We furthermore identified another 26 English language
publications via citation tracking. The numbers reflected the main language of the respective
database, so that for instance most Portuguese and Spanish studies were found in the database
Redalyc, but few or no such studies were found in Web of Science or EBSCO. This underscores
the importance of searching for studies in a variety of languages and in a variety of databases if the
aim is to foster an inclusion of studies from diverse contexts globally.
This exclusion process left us with a total of 73 studies. Figure 7 shows the research
affiliation countries of the first authors of each of the 73 studies: the US, the UK, and Australia are
highly represented. They are followed by Canada, Germany, Denmark, and Cyprus. One or two
studies each stemmed from Switzerland, Norway, Sweden, Croatia, Brazil, Spain, the United Arab
Emirates, Lebanon, Austria, Luxembourg, Ireland, New Zealand, and South Korea. There were no
studies from the African continent among the 73 studies, and only a single one from Latin America,
specifically from Brazil. Certainly, the findings are not generalisable—they refer to a very specific
keyword search, related to a very specific subject (the experience of psychotherapy with refugee
clients) in very specific databases. However, they provide an idea about the dominance of certain
countries in psychological research. When we saw this distribution of studies among countries, we
started wondering if we as meta-researchers had contributed to a bias in the selection of studies.
Unfortunately, we had not kept any record of the countries of origin for all of the 685+26 primary
studies we had identified via keyword search and citation tracking. Therefore, we could not deduce
how our selection process might have excluded some of the diversity potentially present among
primary studies. In terms of language, the 73 primary studies included 65 English, six German, one
Spanish, one Portuguese, and no French publication. When we continued our selection process,
the diversity of studies’ origin and language decreased even further, and we ended up with 10
studies, which we included in our analytical procedure, leaving us with nine English and one
German publication. Interestingly, none of the studies in the final selection were from the US.
Instead, we included three Australian studies, three studies from the UK, and one study each from
Sweden, Germany, Switzerland, and Denmark.
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Figure 7
World map of primary studies’ origins
In this our synthesis did not achieve its original goal of including studies from non-Western
countries or with a diversity of languages. Despite using Ibero-American and francophone
databases, as well as keywords in five different languages, the final selection of studies was
exclusively composed of investigations from Western countries. Of course, part of the explanation
might be that there is simply a lack of research on this specific topic in non-Western countries
(Teixeira et al., 2013). This explanation seems reasonable; however, as qualitative researchers and
meta-researchers interested in reflecting positionalities we might come up with additional
explanations. Firstly, only through our Brazilian research team members had we come to be aware
of the Ibero-American database Redalyc and the Francophone database Repère. Thus, it may be
the case that our lack of knowledge about adequate databases from other non-Western countries,
as well as about the research landscape in such countries, generally, prevented us from identifying
and using appropriate databases and search engines.
Secondly, the selection criteria of our QES study might have given preference to a Western
way of conducting research and not allowed different ways of generating knowledge to enter the
analytical stages. How so? Qualitative researchers have long called attention to the need for
researchers to reflect on their biases and positionalities, a process called “bracketing” or
“reflexivity” (Hill et al., 2005; Williams & Morrow, 2009). The idea behind bracketing is to reflect
about how researchers’ experiences, socialisation, and implicit assumptions may be influencing a
study’s aims, design, methodology, findings, and interpretations. However, it is not only the
upbringing, the political position, and the sociocultural context that affects how we do and how
we see science, but also our socialisation and reproduction of a certain scientific and intellectual
94
style (Galtung, 1981; Koutsantoni, 2005). As psychological (in my case Western) scientists, we
acquire and perpetuate a certain way of thinking about science, of doing science, of writing
scientific articles, and of evaluating scientific investigations. Cross-culturally there are differences
in intellectual traditions, which can be attributed to literacy practices, approaches to politeness,
structures of communities, and cultural characteristics more generally (Koutsantoni, 2005;
Mauranen, 1993; Vassileva, 2001). Galtung (1981, p. 838) looked at intellectual styles across cultures
and described the primary approach for intellectualists or their work in the following countries:
US (“saxonic”): How do you operationalize it?
UK (“saxonic”): How do you document it?
Germany (“teutonic”): How can you deduce it from basic principles?
France (“gallic”): Is it possible to say this in good French?
Japanese (“nipponic”): Who is your master?
Thus, the anglophone academic discourse, for instance, encodes the principles of
positivism and empiricism (Bennett, 2010). Scientific articles from North America, the UK, and
Australia are constructed within that specific discourse community (Koutsantoni, 2005). The
intellectual style and the academic discourse then often translate into specific writing styles. For
example, in the anglophone psychological science universe, authors are trained to formulate short
and concise sentences, in order to make their texts easily accessible and understandable for the
reader (Clyne, 1987). Several studies have contrasted the anglophone intellectual and writing style
or academic discourse with those of other countries such as Bulgaria (Vassileva, 2001), Germany
(Clyne, 1987), Greece (Koutsantoni, 2005), or Portugal (Bennett, 2010). For instance, in the
German tradition texts are less designed to be easy to read, but to focus on providing readers with
theory, knowledge, and incentive for thought (Clyne, 1987). In many Romance language contexts,
an example here being Portugal, academic texts, particularly in the humanities, demonstrate
wordiness and redundancy, an inclination towards indirectness and much use of figurative language
(Bennett, 2010). These differences between academic writing styles are but small examples of much
variation that can exist in how to do science and how to report on it, influenced greatly by cultural
values and norms (Koutsantoni, 2005). Epistemological differences exist across the various
scientific communities, and knowledge is constructed in diverse ways across cultures (Koutsantoni,
2005) and across the diverse disciplines and methodological approaches (Bennett, 2010). The
diversity of intellectual and writing styles is certainly an indicator for this.
Thus, in the process of a QES project, we too, as researchers from a certain scientific
tradition and academic discourse, are implicitly and explicitly guided by these preferences for
intellectual styles and by assumptions about what makes up correct or good science. In meta-research
the learned evaluations may enter explicitly, for instance in our quality criteria, and they may guide
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us implicitly when evaluating a study and its reporting style. However, as a consequence we are
prone to prefer studies that were conducted and reported in an intellectual and writing style that is
similar to our own (e.g. concise, “objective”, easy to read) over those that demonstrate a different
style (e.g. wordy, “subjective”, figurative). It is likely that in the selection process of a QES project,
our own (implicit) criteria will be applied—for instance, for anglophone evaluators a search for
operationalisations, documentation, and clear and concise writing. This, in turn, risks rejecting a
style that differs from our own as “badly written” or even as bad science altogether (Bennett, 2010).
We might in consequence exclude meaningful primary studies for the synthesis based on what may
be considered a cultural difference in academic, writing, or intellectual style. In this way a certain
manner in which knowledge is constructed will be further perpetuated, despite the diversity of ways
to construct (psychological) knowledge that exists internationally (Bennett, 2010; Gone &
Kirmayer, 2010; Summerfield, 1999).
Conclusion
There is a plurality of academic and intellectual styles across the world, but the anglophone
academic style is certainly the dominate one in most disciplines, including psychology (Bennett,
2010). When conducting a QES study, meta-researchers should be aware of their own
positionalities, including their preferences for a certain academic and intellectual style and for a
specific way to conduct research, and reflect upon how these preferences may influence their
selection of primary studies. In the best case, a QES study is conducted by a team of researchers
(Paterson et al., 2001) which come from a diversity of contexts, bringing with them multiple
language skills and multiple perspectives on science and criteria for good science and scientific
writing. This may be a way to encounter the hegemonic anglophone academic discourse and its
practices, which has largely rejected scientific features that are not in line with its positivistic and
empirical assumptions (Bennett, 2010). The result might be a greater diversity in terms of writing
and academic styles, epistemologies, and countries of origin among primary studies that are
included in a synthesis, which might ultimately help to foster the highly needed greater plurality in
the psychological sciences altogether.
Merging without Losing Meaning: Analysis of Primary Data
On thematic synthesis
While analysing the primary studies we had identified and selected for our QES study, we
followed the method proposed in thematic synthesis (Thomas & Harden, 2008). This involved
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line-by-line coding of the results sections of the primary studies. This way, every sentence in the
results section was coded at least once. The research question we had in mind for our project was
temporarily set aside to approach the data inductively at this stage (Thomas & Harden, 2008). The
second stage involved looking for differences and similarities in codes and organising them into a
hierarchical tree structure, placing the codes under higher-order themes. This is what Thomas and
Harden (2008) called the development of data-driven, descriptive themes. These themes are still
very close to the data from the original studies and do not address the research question(s) directly.
However, the descriptive themes do not necessarily overlap with those categories or themes
developed by the researchers of the primary studies. The final stage of analysis is the generation of
theory-driven, analytical themes whereby meta-researchers aim to generate answers to their
research question(s) from the descriptive themes. Thus, analytical themes are developed by looking
at the descriptive themes through the lens of a theoretical framework (our research questions;
Thomas & Harden, 2008). There are more aspects to this process such as the involvement of
several independent coders, but here it will suffice to have this general idea about the analytical
process. The analytical procedure is outlined in detail in the original publication of Thomas and
Harden (2008). In what follows, I will focus on the challenges we encountered while analysing our
primary studies.
A first problematic issue for us was that we found the difference between analytical and
descriptive themes often somewhat blurred, as already the grouping of codes into certain
descriptive themes contained an analytical choice by our researchers. It may appear as just a minor
difference in the understanding of the word “analytical”. However, it really posed a challenge to
our analytical process, since it was sometimes difficult to make sure that “descriptive” themes were,
indeed, as much data-driven as possible. This may be a familiar problem to many qualitative
researchers, and it can be facilitated using several independent coders, who discuss the codes and
their hierarchical organisation into descriptive themes.
Analysing first- and second-order interpretations

Secondly, while we, as meta-researchers, were conducting a third-order interpretation, we
were confronted with data that contained not only the account of participants (first-order
interpretations) but also the analytical thoughts and conclusions of researchers (second-order
interpretations). This is, of course, the result of conducting a QES investigation and not a primary
study or secondary analysis, whereby only the original data (i.e. the accounts of participants) would
be analysed. As a consequence, already the codes and descriptive themes include analytical aspects,
namely those developed by primary researchers. We encountered the question of how to proceed
if one, as a meta-researcher, does not understand and cannot reconstruct the inference a primary
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researcher made from a certain quote provided in the article. For instance, in a primary study, a
researcher may draw a conclusion such as “participants struggled to accept new perspectives in therapy”18
and provide a quote that, in the eyes of the meta-researcher, is not a good illustration of the
statement. Instead, it may be perceived as carrying a different meaning, as for example in the quote,
“I don’t like it when my therapist talks about things that have nothing to do with me or my problem”. In cases
like this, our team decided to code both the conclusion of the primary researcher and the quote,
separately. We assumed that the analytical conclusion of the researcher was not purely deduced
based on the exemplary quote, but had additional supporting data. We, as meta-researchers, do not
have access to the complete data set and can therefore neither confirm nor contest the conclusions.
This is in line with Weed (2005), who stated that meta-researchers should trust the original
interpretations of primary researchers, or if this is not possible, exclude the respective primary
study from the QES project. A reason for this argument is the fact that the original interpretations
are tied to the context of the primary research, and this context cannot be recaptured in a QES
study (Weed, 2005). Furthermore, it is the idea behind the meta in the QES concept to analyse not
only first-order interpretation but also second-order interpretation, thus those of primary
researchers. Therefore, we coded the statement of the primary researcher as “struggle to accept new
perspectives in therapy” and that of the participant as “negative = therapist talking about unrelated things”,
so that both statements were given space and value.
Abstracting and aiming for a single story while keeping in-depth meaning
However, the inclusion of both levels (first- and second-order interpretations) posed
further challenges. It made it sometimes difficult to develop themes from codes that were rich in
content. In some cases, there were only single quotes from participants for a potentially relevant
theme. Many qualitative researchers have argued against using frequency counts of themes among
participants as a measure for the importance of a theme (Braun & Clarke, 2006, 2019). Determining
the importance of a theme without having access to any or to sufficient knowledge about the
context of participants and the primary study, however, is quite difficult. Should we include a single
experience as a whole theme, as it stood out in some way? Should we focus on the experience of
the “majority” or single out certain experiences? Also, how should we proceed with diverging, but
single experiences, i.e. experiences that were described as opposing those of the majority of
participants, but reported by only one or two participants across studies? For instance, a primary
18The quotes cited here were inspired by primary studies but invented by the author in order to make the point without
compromising the accounts of primary researchers or participants.
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article may state, “Only one participant described the experience of diminished satisfaction in the
process”. We struggled to decide with the little information we had on participants and the question
of whether to generate a new theme for these instances or whether to ignore the statement and
code. Most meta-researchers have in mind to create a coherent and concise report suitable for
publication and are thus bound by word limits of journals. As a consequence, diverging experiences
and interpretations across studies, between researchers and participants, or among the participants
of a single study themselves, as well as single statements of participants, often disappear beneath
the conciseness and the story the research article aims to tell. In our QES study we decided to
include an “ambivalent” category to tackle these issues. In this category we integrated findings and
experiences that differed among primary studies or participants, or were perceived as ambivalent
within participants themselves.
Meanwhile, even when we have figured out a way to approach what “makes up” a theme,
it remains a challenge to maintain the in-depth meaning of participants’ experiences. This is already
the case in primary research in which primary researchers are faced with the task of condensing
participants’ accounts in order to report research findings. Meta-researchers, who work on an even
more abstract level, have to deal with a somewhat greater tension between needing to abstract in
the generation of themes, for the sake of creating a concise report with insight and information,
and the challenge of maintaining some of the concreteness and depth of the experiences of
individuals.
Inferring from explicit and implicit statements

A further difficulty in the analytical process arose from the fact that even if we look at a
single order of interpretation (that of the participant or that of the primary researcher), there are
different levels of explicitness to a statement. There is a difference in saying, “I think the
relationship is the key to the therapy” or “It was really seeing my therapist that helped me to get
better”. The first statement is an explicit opinion of a participant, who underscored the importance
of the therapeutic relationship in a therapy. It can thus be coded and organised under a theme such
as “importance of therapeutic relationship”. The second statement also refers to a helpful factor,
“seeing my therapist”, but it can mean a number of things, one of them being that the relationship
played the most important part in the healing process. However, the participant may also have tried
to say that going to therapy in general was helpful. Organising the statement under the theme
“therapeutic relationship” may thus be too much of a jump ahead. Creating the theme “helpful =
seeing my therapist” is close to saying nothing if we wish to answer the question of how the therapy
is helpful. Furthermore, it is problematic to create new themes for each code, that differs slightly
from the others, since after a while we would end up with an unwieldy number of themes. After
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all, it is the objective of the analytical process to condense, translate, and integrate findings of primary
studies. This is impossible if we do not dare to abstract from our single codes and participants’
first-order interpretations and primary researchers’ second-order interpretations. Certainly, this is
a challenge encountered not only in meta-research but also in qualitative research in general
(Williams & Morrow, 2009). Meanwhile, as meta-researchers are provided with less context (as for
instance the participants’ accounts before and after a specific quote are often not accessible), the
problem is somewhat inflated. Analytical decisions have to be made based on limited data and
limited context.
This highlights the need to keep transparent and systematic records about steps and
decisions taken by meta-researchers along the way. Meta-researchers conducting a QES
investigation have to take notice of instances in which themes are developed out of direct or explicit
statements, and therefore, clear data-driven themes, or when they are generated out of indirect or
implicit statements, and, thus, somewhat more inferred themes. It also speaks again to the
usefulness of conducting a QES study with a team of researchers who can reflect upon and discuss
these decisions.
Conclusion
Conducting the analysis for a QES project is a difficult and lengthy process. A sort of
paradox or tension emerges for meta-researchers of qualitative research—the question of how to
merge qualitative levels of abstraction, implicit and explicit accounts, and first- and second-order
interpretations, and how to condense and integrate findings from primary studies, while keeping
the depths of the results of primary studies and without losing the meaning that participants give
to their experiences (McLeod, 2013). The aim of QES is rarely to obtain the frequency of themes
across participants and across primary studies19, but to generate insight beyond numbers. At the
same time, meta-researchers wish and need to reduce and condense findings. So, the question arises
of what it is that we can focus upon and generate in terms of results. Is it the particular “beautiful”,
“surprising” data? Is it the experience of the “majority” across studies? Or is it only the data that
best answer our research questions? Furthermore, we are challenged by the puzzle of how much
of a “jump ahead” we can take as meta-researchers: how close do we need and wish to stay or how
far can we move away in our analysis from the primary researchers’ interpretations and participants’
accounts? If we try to include all findings in detail, our results lose the capacity to attain and
transport an understandable and more general meaning. On the other hand, accentuations of
19 Which might also be an option; see Hill et al., 2005; Weed, 2005.
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certain findings over others are, of course, subjective interpretations by meta-researchers and risk
obscuring and losing the meaning people give to phenomena. Certainly, qualitative researchers and
meta-researchers do not claim objectivity but rather aim to provide “subjective testimonial to other
people’s voices” (Ahearn, 2000b, p. 15). Meanwhile, the tension between reducing and synthesising
and maintaining depth and meaning remains a problem for which there may not be a single
solution. Factors such as keeping records and working in teams to mutually reflect upon the
constant decisions that have to be made can help to surface the tension in a transparent form. Also,
it may help to conceive the whole research process from the start as an iterative process in which
themes are created, but in which meta-researchers always refer back to the primary studies and
repeatedly condense, categorize, break categories up again, and fill them with content and meaning.
All decisions along the way can be made in diverging ways by different researchers at different
points in time—the important point, as with qualitative research in general, is that decisions are
justified and transparently reported. In a way, meta-researchers will always have to reduce findings
from primary studies, that already have performed a reduction of participants’ experiences
themselves. This will most likely lead to a thinning out of “the desired thickness of particulars”
(Sandeloswki et al., 1997, p. 366). So the question will remain of how we can communicate the two
facets—a) clarity, abstraction, and a single story, and b) the depth and complexity of human
experience.
Overall Conclusion and Outlook

The objective of the present article was to introduce qualitative evidence synthesis to the reader
and outline some of the benefits of using meta-research in qualitative inquiry. Furthermore, the article
aimed to shed light on two particular challenges of conducting QES, the first being the difficulty of
including primary investigation from diverse countries, and the second the difficulties in the analytical
procedure, particularly the tension of reducing findings and maintaining the depth and meaning of
experiences. The most important recommendations for researchers wishing to conduct QES
emerging from our own experience are these:
1. Work in an intercultural team in which various languages are present and in which there is
space for mutual reflection on
a. Diverging epistemologies and preferences for academic, intellectual, and research

styles;
b. Use of databases from a variety of countries;
c. Use of keywords in diverse languages; and
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d. Inclusion (criteria) and exclusion (criteria) of studies.
2. Keep notes on decisions being made along the way:
a. How do you deal with explicit/implicit statements?
b. How do you address apparently diverging first- and second-order interpretations?
c. How do you deal with “singled out” or contrasting experiences by a few or single
participants or with ambivalent experiences across participants and primary studies?
d. How do you aim to keep in-depth meaning while reducing your research and findings
to a concise report?
3. The use of frequencies for themes may be an option for QES as it is for primary qualitative
researchers (e.g. Hill et al., 2005). In some instances, in which it is difficult to decide on the
importance of themes, this methodology may be somewhat easier and help to gain
orientation in the process. However, there is also the need in meta-research, that is often
stressed by qualitative researchers in general, to look for the meaning beyond the
“numbers”.
4. And finally, after reflection, make and justify your decisions and be open to the fact that other
researchers may have decided differently.
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Section II
Mental Health Support for Refugees in

Brazil
Chapter 4
From a Synthesis of the Literature to
Research in Brazil
Section II | Chapter 4 Brazilian Context
The objective of this chapter is to explain the reasons for conducting an investigation on
the experiences of psychologists who work with refugees in Brazil. Additionally, the chapter aims
to provide some background information on the mental healthcare, as well as on the migrants and
refugees in Brazil.
A Rationale for Investigating Experiences in Brazil

The reasons for why I decided to investigate the perspectives of psychologists who work
with refugees in Brazil are manifold. First of all, during my previous stays in Brazil I had gotten to
know a psychological service that specialised in the work with immigrants and refugees as patients.
I have had the chance to learn about the work of the psychologists in this clinic – an experience
for which I am still deeply grateful since this would define much of my further path. A later position
at a psycho-social centre for refugees and asylum-seekers in Germany allowed me a personal
comparison between the work of professionals in the same area in Brazil and in Germany. These
experiences and the time I spent at a Brazilian university evoked much of my interest to deepen
my insights into the approaches of psychologists in Brazil. I developed some initial ideas about
how and to what extent academic cultures may differ across countries. For instance, I realised that
principles of empiricism and positivism were deeply encoded in the way I had learned to conduct
psychological research. In Brazil, in contrast, the discipline of psychology was much more
perceived as, what Holzkamp (1983) called a “qualitative Subjektwissenschaft”, uma ciência da
subjetividade, a qualitative subject science.
Secondly, due to the time I had spent in Brazil, I already had a network in the country; I
was able to speak Portuguese and to interact with people in a way that felt very natural. Choosing
to undertake my fieldwork in Brazil, I did not feel as a complete stranger or intruder coming from
the outside just to take data away in a kind of parachuting research (Davies & Mullan, 2016; Hook
& Vera, 2020). Instead, I was integrated into an academic community at a Brazilian university, and
I could count on the support of my Brazilian colleagues. This condition allowed me access to
several spaces and projects of mental health support, and to find the participants for my study.
Thus, my decision to interview psychologists in Brazil was primarily built on years of previous
experiences I was so lucky to have had in the country, which made me curious about psychological
perspectives from the non-Western world, humble to acknowledge these perspectives and which
provided me with some of the practical skills and connections to undertake such an investigation.
However, there were, of course, other reasons and explanations for why it made sense to conduct
investigations on the topic of MHSR in Brazil.
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The reasons for why there is a great need for the psychological sciences in general to pay
more attention to and include more studies from non-Western countries are outlined in detail in
Chapter 1 and Chapter 3. The meta-synthesis reported in Chapter 2 and 3 showed that it is a great
challenge to identify research from non-Western country, which is, to a large extent, due to the
limitations emerging from our own positionalities and preferences of specific academic styles and
of ways to conduct research. It may, furthermore, relate to the fact that in the field of psychological
research concerning the mental health and mental health support for refugees, most investigations
actually stem from high-income and Western countries, despite the fact that 85% of displaced
people are being hosted by developing, non-Western countries (UNHCR, 2019). In South America,
there is little research concerning refugees in general (Braga Bezerra et al., 2019; Moraes Weintraub,
2012; Teixeira et al., 2013). Therefore, my choice of a research context in South America was also
based on the objective to contribute to a closing of this gap in the research.
Brazil, specifically, is an interesting context to study in terms of mental health and mental
health support for refugees as the country has taken a pioneer position to regulate protection of
refugees in South America (Becker, 2015; Jubilut, 2006; Savabi, 2014; White, 2012). Brazil ratified
the UNHCR Convention of 1951 as the first country of the Southern cone and was the first in the
same region to pass a refugee law (Savabi, 2014; White, 2012). The country has also been considered
an emerging resettlement country for refugees since the beginning of the twenty-first century
(Becker, 2015; Jubilut et al., 2008). Furthermore, Brazilian legislation includes a comparatively
broad version of the definition of “refugee” following the expanded definition of the Cartagena
Declaration (Bógus & Rodrigues, 2011; Jubilut, 2006; Leão, 2011; Savabi, 2014). In contrast to
many countries in Western Europe such as Germany, displaced people who apply for asylum in
Brazil are allowed to work directly after submitting their application (Bógus & Rodrigues, 2011;
Jubilut, 2006; Leão, 2011) – a fact, that can make a big difference for mental health processes
(Comtesse & Rosner, 2019; Davidson et al., 2008; DGPPN, 2016). Similarly, even though refugee
applications are processed slowly in Brazil, detention and deportation do not exist (Jubilut, 2006;
Leão, 2011). These two factors have been most strongly linked to future insecurities and associated
mental health problems in refugees (Davidson et al., 2008; Momartin et al., 2006).
Meanwhile, there is very little information on the mental health of refugees in Brazil
(Teixeira et al., 2013). The demand for a better understanding of this subject, as well as of
specialised mental health care services for refugees has increased dramatically (Bógus & Rodrigues,
2011; Moreira & Baeninger, 2010), in particular with the earthquake in Haiti in 2010 and the
humanitarian crises in Venezuela from 2016 onwards (Barros & Martins-Borges, 2018; CONARE,
2019).
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Migrants and Refugees in Brazil

Debates of ethnicity and interculturality are framed very differently among different
countries (Kirmayer, 2012a). Brazil has often been portrayed as a welcoming country, a country of
migration in which there are no ethnical conflicts despite a great cultural diversity (Freyre, 1987;
Patarra & Fernandes, 2011; Zamberlam, 2004); a country in which apparently everyone can be
Brazilian, in which the difference between “Kabul, Moscow and Miami” does not seem to play a role,
since everything is equally far away from the reality of Brazilians' lives (Zamberlam, 2004; p. 16).
However, this view has been strongly criticized as a “Democracia-Racial Myth”, with the main concern
being that it unlawfully levels out real differences between people, e.g. in terms of wages,
imprisonment rates and educational qualifications (see for instance de Souza, 2015). According to
Zamberlam (2004) and others, the colonial ideal of the “good migrant” as the “white, healthy settler and
worker” still exists in Brazil and xenophobia, discrimination and prejudice against migrants who do
not match this idea are omnipresent (Barros & Martins-Borges, 2018; Silva-Ferreira et al., 2019;
Jibrin, 2017; Jung et al., 2016; Lodetti, 2018; Moreira & Baeninger, 2010; Zamberlam, 2004).
Brazil, the fifth largest country by area in the world, is composed out of 27 federative units
(26 states and one federal district) and has over 211 million inhabitants in total (IBGE, 2019). In
the last Brazilian census from 201020 92.529 people stated that they were migrants and had lived in
another country five years ago (Martins-Borges, 2013). The country has about 1,5 million
“foreigners”, in the sense of people born in another country, regardless of their current citizenship,
which represents about 0,7% of the population. About 31% of these people are from Portugal,
10% from Japan and 8% from Italy. However, the figures vary greatly depending on the definition
of the terms “foreigner” and “migrant” (IBGE, 2010), so that a direct comparison with the statistics
in other countries is difficult (Kizilhan, 2006, p. 162). It is clear, however, that Brazil has far fewer
people with migration background than countries such as Canada and that Brazil is below the global
average in terms of the proportion of foreign population (Bozorgmehr et al., 2016).
The history of migration in Brazil begins with the colonisation by the Portuguese in the
16th century, which also was the beginning of the first forced migration – the displacement of
indigenous populations and the deportation of about four million African people, mainly from
Guinea, Angola, Mozambique and Nigeria, which proceeded until the abolition of slavery in 1888
(Patarra & Fernandes, 2011). In the 17th century, there were already more deported African people
than settled Europeans in the country (Patarra & Fernandes, 2011), which still has an impact on
20 The new Brazilian census from 2020 is expected to be shortly published. See: https://censo2020.ibge.gov.br/
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Brazilian society today: It is marked by the traces of African cultures and about half of the
population has partly ancestors from an African country (Patarra & Fernandes, 2011). In the
following 130 years, due to shifts in the political and economic situation, the country altered in
phases from a country of strong immigration of workers (between 1872 and 1940 about 5 million
Europeans came to Brazil) to a country of emigrants (Patarra & Fernandes, 2011). In 2001, more
than 2,5 million Brazilians were living abroad, in 2004 there were about 4 million, which, in other
words, meant that for every person who immigrated to Brazil there were three emigrated Brazilians
(Zamberlam, 2004). From 2010 onwards, this picture changed once again, as Brazil increasingly
received immigrants, especially from neighbouring countries (particularly from Bolivia and Peru),
but also from the Northern Hemisphere (Patarra & Fernandes, 2011; Oliveira, 2017), and as
formerly emigrated Brazilians returned (IBGE, 2010). The country's economic development was
particularly responsible for these increases, but also the introduction of humanitarian status visa
for migrants from Haiti (Martins-Borges, 2013). In particular after the earthquake in Haiti in 2010,
the proportion of Haitian migrants augmented greatly in Brazil. In 2014, there were more than
50.000 Haitians living in Brazil. Since 2013, Haitians represent the largest foreign workforce in
Brazil (Véran et al., 2014). Most recently, the humanitarian crisis in Venezuela from 2016 onwards
caused more than 4,5 million Venezuelans to leave their country of which over 260.000 crossed
the Brazilian border (CONARE, 2019; UNHCR, 2020), making Brazil the fifth largest host country
for displaced Venezuelans (UNHCR, 2020).
Refugees in Brazil
The total number of recognised refugees exceeded 11.000 in Brazil by December 2018,
with over 161.000 people still waiting for their asylum claims to be processed. This compares to a
number of 4.500 recognised refugees in 2009. About 80.000 new applications were submitted in
2018 alone (CONARE, 2019). Even though the numbers are still relatively small compared to
countries such as Turkey, Pakistan, Lebanon and Germany (UNFPA, 2015), for Brazil they
represent a considerable increase in asylum applications compared to previous years – again related
to the earthquake in Haiti, the humanitarian crisis in Venezuela, but also the Syrian war. Indeed,
most asylum applications were received from Venezuelans, followed by Haitians and Cubans in
2018 (see Figure 8) and the highest number of official refugee statuses were granted to Syrians
(CONARE, 2019).
In terms of geographical distribution, most applications of asylum in 2018 were received in
the Brazilian state of Roraima (63%) which borders with Venezuela and Guyana, followed by
Amazonas (13%) also at the border with Venezuela and, furthermore, with Peru and Colombia, as
well as by São Paulo (12%) which is situated in the Southeast of the country (CONARE, 2019).
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The three Southern Brazilian states, Paraná, Santa Catarina and Rio Grande do Sul each received
2% of the asylum applications in 2018.
Figure 8
Map of countries of origin of asylum-seekers in Brazil in 2018 (adapted from CONARE, 2019, p. 19)
The growing number of displaced people in Brazil has evoked some policy changes (Leão,
2011). For example, the country has increased the amount of humanitarian aid spending from US$
2,6 million in 2005 to US$ 14,9 million in 2014 (UNFPA, 2015) and in September 2013, the country
authorized Brazilian embassies to issue special humanitarian visas for people affected by the Syrian
war to facilitate their flight to Brazil (Leão, 2011). The integration of refugees is a key component
of the Latin American countries' 2004 Mexico Plan of Action, which aims to give refugees access
to basic structures in health, education, employment and housing sectors (Barreto & Leão, 2010;
Gilbert, 2006; Jubilut, 2010). In November 2017, the Brazilian state approved the “nova lei de
migração” – a new law for migrants, that aims to simplify administrative procedures for immigrants
in Brazil, particularly regarding the recognition of stateless people (Ministério da Justiça e Segurança
Pública, 2017). It substitutes the “Estatuto do Estrangeiro” which was the legislation for migration
policies in Brazil introduced in 1980, and in doing so, shifts from a perspective of migrants as risks
for national security to a human rights perspective, an emphasis on the guarantee of rights and
non-discrimination of migrants (Assis, 2018; Lodetti, 2018; Oliveira, 2017). Among other things,
the new law facilitates the passage of by-laws for the concession of humanitarian visa (Oliveira,
2017). Meanwhile, the new law only passed with much opposition, and 20 changes by vetoes
(Lodetti, 2018; Uebel, 2019) including, for instance, against the concept of “migrant” in Article 1.
The new law now includes only the definitions of “immigrant”, “emigrant”, “border resident”,
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“visitor” and “stateless person”. According to Assis (2018, p. 619), the veto against “migrant”
expresses the persistence of aiming to place migrants closer to the idea of strangers and foreigners,
instead of fostering a perception of migrants as mobile subjects in the contemporary world, which
was what the commission originally set out to establish. Another veto concerned the extension of
the residence permit to persons without direct family ties (Articles 37 and 40). This modification is
considered a step backwards, since it does not recognise contemporary family arrangements, which
can involve ties of affection between people outside the more traditional concepts of family (Assis,
2018).
Despite its role as a political and legal model for refugees in Latin America (Bógus &
Rodrigues, 2011; Jubilut, 2006), Brazil faces major structural deficits and a lack of public policies
for the reception, integration and care of displaced people (Bógus & Rodrigues, 2011; Jubilut, 2006;
Leão, 2011). Aydos et al. (2018), reported, for example, that about 37% of displaced people lived
on the street after arrival in Brazil. It is mostly the civil society that assumes responsibility for the
reception and integration of refugees. The Catholic Church in particular and associated
organisations, such as Caritas, take up important roles in this regard (De Santana & Neto, 2015;
Leão, 2011). Yet, there is still a lack of research on refugees and their living conditions in Brazil
(Aydos et al., 2008; Braga Bezerra et al., 2019). The deficits in the reception and care of refugees
are inseparably linked to the general socio-political problems in Brazil. Similar to many low- and
middle- income countries, Brazil has a poverty rate of over 30%, more than 38 million Brazilians
work in precarious jobs, there are numerous favelas with poor sanitation, and Brazil has one of the
highest levels of social inequality in the world (Barros et al., 2001; Ortega & Orsini, 2020). Brazil,
according to Barros et al. (2001, p. 1), is an “unequal country facing a historical challenge - it has to confront
the legacy of social injustice that excludes a significant proportion of its population from access to minimal conditions
of dignity and citizenship”. At the same time, many authors are convinced that Brazil does have the
(financial) means to fight poverty and inequality (Barros et al., 2001) and to improve the situation
of refugees in Brazil (Martins-Borges, 2013). The main obstacles to the social and economic
integration of refugees in Brazil seem to be the lack of employment and housing, as well as
xenophobic attitudes and discrimination within the population (Barros & Martins-Borges, 2018;
De Santana & Neto, 2015; Moreira & Baeninger, 2010), and the lack of coordination between
national, federal and municipal institutions (GAIRF, 2015).
Mental Healthcare in Brazil

The following section shortly outlines Brazilian approaches to and services of mental
healthcare and describes the current knowledge around mental healthcare for refugees in Brazil.
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In 1988, the national Brazilian unified healthcare system (Sistema Único de Saúde, SUS)
was established with the objective to provide comprehensive, universal healthcare for everyone
free of charge (Loch et al., 2016; Mateus et al., 2008; Paim et al., 2011; Severo & Dimenstein, 2011).
The SUS is based on an ample understanding of health, integrating physical, cultural and
socioeconomic factors (Böing et al., 2009). It aggregates all health services of federal, state and
municipal public institutions (Mateus et al., 2008). The SUS functions in a network with a
pyramidical structure from the least complex level (e.g. serviços da atenção primária) to the most
complex level of care such as hospitals (Severo & Dimenstein, 2011). Most psychologists in the
public sector work for some unit of the SUS or the Unified System of Social Service (SUAS).
Being largely based on the Caracas declaration (Mateus et al., 2008) and strongly influenced
by the Anti-Psychiatry Movement and the Democratic Psychiatry in Italy (Goulart & González
Rey, 2016), Brazilian mental health policy aims for a model of open, family and community care
(Marsillac et al., 2018). Since 2011, one important component of the SUS is the network of
psychosocial care (RAPS, Lima & Guimarães, 2019) which cares for people with mental health
problems. The RAPS consists of services such as psychosocial care centres (CAPS), residential
therapeutic care (SRT); community and culture centres, transitory accommodation units (UAs),
and comprehensive care beds in general hospitals (Ministério da Saúde, 2013). The CAPS,
inaugurated as alternatives to traditional asylums, form the cornerstone of mental health support
in Brazil (Goulart & González Rey, 2016). They care for people with mental health problems by
working in multiprofessional teams who aim to locate resources within the community. The teams
make home visits, implement community activities, and provide therapeutic care adapted to each
patient (e.g. family therapy, group therapy session, individual psychotherapy, therapeutic
workshops, work-related workshops; Goulart & González Rey, 2016; Ministério da Saúde, 2013;
Salles et al., 2016). Through a resolution of the National Supplementary Health Agency (Agência
Nacional de Saúde Suplementar) health insurances in Brazil are obliged to cover psychotherapeutic
services, but also to limit the number of annual psychotherapy sessions (Nicaretta, 2009).
Certainly, the creation of the SUS has increased the provision of and free access to mental
healthcare services. However, problems remain, such as units being poorly articulated, fragmented
and too bureaucratic (Böing et al., 2009; Severo & Dimenstein, 2011), precariousness of healthcare
services in many municipalities due to limited governmental spending on (mental) healthcare and
an unequal coverage of services across regions (Doniec et al., 2018; Marsillac et al., 2018).
Psychotherapy and psychotherapists in Brazil
Psychology was recognised as a profession in Brazil in 1962 by a federal law, which enabled
clinical psychologists to work in public healthcare institutions a decade later (Alberti et al., 2016).
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Nowadays, clinical psychologists in Brazil can work in various institutions of the public healthcare
sector such as in the psychosocial care centres (CAPS), in residential therapeutic care, in community
and culture centres and in hospitals. They can also work in private practise as psychotherapists and
counsellors, at private and public universities, as well as at non-governmental organisations.
To become a psychologist, individuals have to finish an undergraduate degree programme,
which conforms to a national curriculum and involves three years of general studies in
psychological science, followed by two years of area-specific and practical internships (Rezende,
2014). For more details on psychology curricula in Brazil please see for instance Bastos and
Gondim (2010) or Rezende (2014). There is no formal license for psychotherapists in Brazil, and
psychologists can work psychotherapeutically after finishing their university degree. There is a
comparably strong divide among proponents of different psychotherapeutic approaches and
orientations in Brazil (Nicaretta, 2009). The dominance of a specific psychotherapeutic orientation
or school depends i.a. on the region in Brazil (Facchinetti, 2018; Rangé et al., 2007). Psychoanalysis,
which caught attention in Brazil in the 1920s following the global trend (Gomes et al., 2015) was
long the preferred orientation by many clinical psychologists (Nogueira-Vale & Rodrigues, 2019)
and continues to exhibit accentuated influence in Brazil (Gomes et al., 2015). In recent years, there
has been an increasing interest in cognitive behavioural therapy (Gomes et al., 2015; Rangé et al.,
2017), which only began to emerge in São Paulo and Rio de Janeiro in the late 1980s (Rangé et al.,
2007). Humanistic approaches, particularly Rogerian psychotherapy, form part of the Brazilian
psychotherapeutic landscape since the late 1960s (Campos, 2005). What is worth mentioning it that
Brazil, namely the Northeast of Brazil, is the founding country of community therapy, an approach
that was developed by the psychiatrist and anthropologist Adalberto Barreto (Barreto &
Grandesso, 2010; Freitas Campos et al., 2013). Community therapy involves a range of elements,
including collective therapy circles, complementary treatments and “living pharmacies” (i.e. herbal
medicines). It is focused on the creation of a shared and public space for suffering and for
generating solidarity among participants, on increasing feelings of personal agency and on relieving
social suffering (Barreto & Grandesso, 2010). The approach is slowly becoming more influential
and has received approval by national public health policy (Bodeker et al., 2020).
The development of community therapy may be seen as an example of how many mental
health professionals in Brazil have been committed to movements of transformation in the
Brazilian society (França Gomes & Dimenstein, 2016). This also becomes visible in the Brazilian
Anti-Asylum Movement and the Psychiatric Reform as well as the Health Reform (França Gomes
& Dimenstein, 2016). In addition, psychologists in Brazil have uttered much criticism regarding a
tendency in mental healthcare to medicalise and individualise mental health problems, and
regarding the silencing of patients’ voices (Nogueira-Vale & Rodrigues, 2019). Many have also
112
called attention to the need of assuming a broader, contextualised and more social perspective on
mental health, mental health problems and mental healthcare (Böing et al., 2009).
Mental healthcare for refugees in Brazil
Refugees who seek help for mental health problems have, like all Brazilian nationals and
foreigners, theoretically access to all the services offered by SUS (Moreira & Baeninger, 2010;
Teixeira Trino et al., 2013). In practice, however, apart from the general gaps in care in this system,
there are special barriers of access for migrants and refugees, such as language differences
(Knobloch, 2015). Only very few specialised services for refugees exist (Bógus & Rodrigues, 2011;
Moreira & Baeninger, 2010), which rely largely on volunteers and non-governmental organisations
(Bógus & Rodrigues, 2011). As is the case for the general reception of refugees, the Catholic
Church also plays a major role in the caring for psycho-social needs of refugees.
In Florianópolis, for example, in Brazil's second southernmost state Santa Catarina, people
from a wide variety of institutions (e.g. universities, churches, NGOs) have come together in 2014
to form a group to support migrants and refugees in the city (GAIRF: “Grupo de Apoio a Imigrantes
e Refugiados em Florianópolis e região”; GAIRF, 2015). In their report, published in June 2015, they
draw attention to the precarious living conditions of refugees in Florianópolis and call for an
expansion of care structures, as well as a sensitisation of the staff of the psychosocial care system
to the issues of migration, interculturality and flight (GAIRF, 2015). In particular, this report
expresses great concern about the current situation of psychosocial care for refugees (Bógus &
Rodrigues, 2011; GAIRF, 2015). In the same city, the “Clínica Intercultural” was founded as an
“outreach-project” of the Universidade Federal de Santa Catarina (UFSC) in 2012 (GAIFR, 2015).
In this university attendance service and clinic, psychologists and psychotherapists work with a
range of psychotherapeutic treatment services specialized in migrants and refugees (GAIFR, 2015).
Meanwhile, the lack of studies, that specifically investigate the current (psychotherapeutic)
care situation for refugees in Brazil and the psycho-social needs of refugees and refugee patients,
continues to persist (Teixeira et al., 2013).
Context and Locations of the Interviews with Psychologists

in Brazil
Gatekeepers and snowball sampling allowed me to establish contact with psychologists
who work with refugees in various regions and settings in Brazil. Table 5 provides some
information on all 32 psychologists who were interviewed for this dissertation. The places of work
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of participating psychologists are furthermore indicated in Figure 9. In order to ensure the

anonymity of participants, no specific information on their work settings can be provided here.
Participants in this project worked in five of the 27 different federative units of Brazil. Most
psychologists who participated in this research project worked in settings in the South of Brazil, in
either Paraná, Santa Catarina or Rio Grande do Sul. Six participants worked in the Southeast,
namely in São Paulo and seven participants worked in the North, in the state of Roraima. Roraima
is located at the border of Venezuela and Guyana. Its capital is Boa Vista and with its population
of only 605.761 it represents the least populated Brazilian state (IBGE, 2019). Regarding the human
development index21, Roraima is ranked place 12 of all 27 Brazilian federative units (UNDP, 2013).
Recently, with the humanitarian crisis in Venezuela, the state of Roraima and particularly the city
of Pacaraima – Venezuela’s main gateways to Brazil – have experienced an enormous influx of
displaced people from Venezuela (UNHCR, 2020). In 2018 alone, Roraima received 50.770
application of asylum (CONARE, 2019). The state of São Paulo with its capital São Paulo is the
most populous state in Brazil (45.919.049; IBGE, 2019). The capital is, furthermore, the most
populous city in Brazil, the Americas, the Western and the Southern Hemisphere. São Paulo is also
the wealthiest state in Brazil. The three Southern states Paraná, Santa Catarina and Rio Grande do
Sul are among the wealthier states of Brazil too and obtain the fifth, third and sixth rank,
respectively, on the human development listing of all 27 Brazilian federative units (UNDP, 2013).
The capital of Paraná is Curitiba and the state has a population of 11.433.957 inhabitants (IBGE,
2019). Santa Catarina with its capital Florianópolis has 7.164.788 inhabitants (IBGE, 2019). Rio
Grande do Sul, where I interviewed only one participant, has a population of 11.377.239 (IBGE,
2019). The states of São Paulo, Paraná, Santa Catarina and Rio Grande do Sul, and additionally
Amazonas, received most relocated Venezuelans from Roraima between April 2018 and December
2019 (UNCHR, 2020). Taken together the six states are hosts to more than 70% of the Venezuelan
displaced people in Brazil (UNCHR, 2020).
The interviews took place during an unsettling time in Brazil – I conducted them from
November until May 2019, during which time a new government came into power. In January
2019, Jair Bolsonaro, a far right, extremely conservative retired military officer, took office as the
Brazilian president, having been elected in October 2018. (Le Tourneau, 2019). His first acts were
to revoke rights guaranteed to Indigenous populations in Brazil (Le Tourneau, 2019), and to change
the conditions under which doctors from the programme “Mais Médicos”, are allowed to practise
21The Human Development Index is scored using indicators including per capita income, life expectancy at birth and
years of education.
114
in Brazil. Mais Médicos was introduced under the government of Dilma Rousseff in June 2013
(Oliveira et al., 2015). The changes weight heavily on the Brazilian healthcare provision, since, as a
consequence more than 8500 doctors, mainly Cubans, will potentially be withdrawn (Alves, 2018).
Meanwhile, particularly Cuban doctors have been highly important for Brazilian healthcare – they
have been providing medical services for about 75% of Brazil’s entire Indigenous population, and
worked particularly in remote and vulnerable regions, such as the semi-arid Northeast and the
Amazon region (Alves, 2018). The disregard of the new president for public health has also become
apparent in the global Covid-19 pandemic, which he approached by demonstrating scepticism of
science, denying the crisis altogether and showing strong oppostion towards quarantine measures
(Ortega & Orsini, 2020). The participating psychologists in our studies in Brazil uttered strong
concerns about cut-backs and modification in the healthcare and social sector. Right after I had
conducted the last interviews in June 2019, the Brazilian government undertook important changes
in Health, such as diminishing society participations like the National Board of Psychology (CFP )
and the Federal Board of Medicine (CFM). It also modified the “National Policy of Mental Health,
Alcohol and Other Drugs,” shifting towards a return to compulsory hospitalisation (Marques &
Nakatani, 2019). Already in 2016, under the president Michael Temer, the Brazilian Senate had
approved the amendment project EC 95 which has frozen public spending for the next 20 years
posing enourmous financial problems to the education, social and health sector (Marques &
Nakatani, 2019). Bolsonaro and his new government further decreased funding for social assistance
and reduced social measures. There was also a rupture in the Brazilan governmental approaches to
immigration during the second turn and particularly after the impeachment of the workers-party
president Dilma Rousseff in 2016 (Uebel, 2019). This rupture resulted in reductions in activities
concerning immigration. For instance, the government under Dilma Rousseff had introduced the
initiative “COMIGRAR” to promote a space for mutual reflexion and strengthen governmental
and non-governmental institutions in the area of refuge and migration in Brazil. With the change
in government, this project, as well as others were shut down (Uebel, 2019). Futhermore, already
in his second week of office in January 2019, Bolsonaro had withdrawn the country form the global
U.N. migration pact (Londoño, 2019).
115
Figure 9
Map of participants’ places of work
More than half of the participants of the fieldwork investigations of this dissertation were
women and 18 participants declared themselves not only psychologists but also psychotherapists.
The average work experience as a psychologist was almost 10 years, but varied greatly between 1-
38 years. The experience of working with refugee patients was less, on average 4 years, but also
with a large range from 1-20 years, whereby only one participant had worked over ten years with
refugees. All participants had at least an undergraduate degree in psychology, 43,8% also had
obtained a Masters’ degree and four participants a PhD. In terms of psychotherapeutic orientation,
most psychologists followed a psychoanalytic or -dynamic approach, eight were specialised in
ethnopsychiatry, four in social and community psychology, three in humanist and existentialist
approaches, two in behaviour therapy and one psychologist followed a systemic orientation. Most
participants were Brazilian-born. Four participants came from other Latin American countries
originally, and two participants from Arabic countries. All participants worked in Portuguese
language with refugees, but many also mentioned working in other languages such as Spanish,
French, English and Arabic. Their psychological care and psychotherapeutic work with refugees
received no financial support in the case of 47% of participants, was co-financed by the university
116
for six participants, by the church for five participants, by an NGO in four cases, the United
Nations in three cases and the Brazilian state in the case of only two participants. 13 participants
worked at a university attendance clinic or service and 11 participants at a centre that was
specifically established to attend to migrants’ and refugees’ needs. Five participants worked with
their patients in the housing of refugee patients. Only three psychologists saw patients in their
private practise and two in a hospital. The pictures on pages 119-122 give an impression of some
of the work settings in which I interviewed participants.
Table 5
Participants’ characteristics (N=32)
Characteristic N/Range % M
Age 23-61 34,8
State of Work
Paraná 10 31,3
Santa Catarina 8 25
São Paulo 7 21,9
Roraima 6 18,8
Rio Grande do Sul 1 3,1
Gender
Women 25 78,1
Men 7 21,9
Profession
Psychologist 32 100
Psychotherapists* 18 56,3
Years of Work Experience
As a psychologist 1-38 9,9
Working with refugees 1-20 3,7
Level of Education
Undergraduate Degree 14 43,8
Masters 14 43,8
Doctorate/PhD 4 12,5
Psychotherapeutic Approach
Psychoanalysis, -dynamic 14 43,8
Ethnopsychiatry 8 25
Social & Community Psychology 4 12,5
Humanistic, Existential 3 9,3
Cognitive-Behaviour Therapy 2 6,3
Systemic Psychotherapy 1 3,1
Country of Origin
Brazil 26 81,2
Argentina 1 3,1
Columbia 1 3,1
Lebanon 1 3,1
Peru 1 3,1
Syria 1 3,1
Uruguay 1 3,1
Working Language
Portuguese 32 100
117
Table 5
Participants’ characteristics (N=32)
Characteristic N/Range % M
Working Language (cont.)
Spanish 22 68,8
English 11 34,4
French 6 18,8
Arabic 2 6,3
Work financed by**
Voluntary 15 46,9
University 6 18,8
Catholic Church 5 15,6
NGO 4 12,5
UN 3 9,3
State 2 6,3
Work Setting**
University Attendance Clinic 13 40,6
NGO/State Centre for Migrant Attendance 11 34,4
Refugee Housing 5 15,6
Private Practice 3 9,3
Hospital 2 6,3
Note. *According to self-report. **Multiple responses possible.
118
Figure 10a
. University Clinic
119
Figure 10b.
NGO Migrant Attendance Centre from the outside and inside
120
Figure 10c
State Migrant Attendance Centre.
121
Figure 10d
NGO Migrant Attendance Centre from the outside and inside
122
Chapter 5
The Psychological Suffering of Refugee
Patients in Brazil
Gesa Solveig Duden, Sofie de Smet & Lucienne Martins-Borges
Submitted to Culture, Medicine & Psychiatry

Section II | Chapter 5 Psychological Suffering of Refugees in Brazil
Abstract
Worldwide there are 79.5 million displaced people, many of which face war, violence, tragic flights
and struggles in host countries. Research shows augmented prevalence rates of mental disorders
among refugees internationally, but little is known about refugee mental health in Latin American
countries. Furthermore, only a few studies have taken into consideration the knowledge of clinical
psychologists who treat refugee patients. The present study examines the experiences of 32
psychologists in Brazil regarding their refugee patients’ psychological suffering and mental
disorders. Semi-structured interviews were conducted in various locations in Brazil and analysed
following a consensual qualitative research approach. Four clusters of refugee patients’ suffering
were synthesised: post-migration stressors, traumatic experiences, flight as life rupture, and the
current situation in the country of origin. The most frequently described conditions in patients
were anxiety and depression. However, the results also show that the use of manuals for the
classification of mental disorders is contested among psychologists in Brazil. Most psychologists
stressed patients’ socio-political suffering and saw patients’ symptoms as normal reactions to their
experiences. There is a need to acknowledge the socio-political suffering of refugees in Brazil and
foster their mental health by tackling current post-migration stressors such as discrimination.
Keywords: Refugee Mental Health, Displaced People in Brazil, Qualitative Semi-structured

Interviews, Asylum-Seekers
124
Introduction
Mental healthcare for refugee patients22 is an issue of international concern and is growing
in importance as the number of displaced people worldwide is rising and now exceeds 79.5 million
(UNHCR, 2020). Refugees are very heterogenous and most do not suffer from mental health
problems. However, many studies find higher prevalence rates of mental disorders in refugees in
comparison to the general population of host countries. For instance, rates of post-traumatic stress
disorder (PTSD) have been found to be up to 10 times higher in refugees than in the general
population (Fazel et al., 2005). Elevated rates of depression and anxiety23 have also been described
in refugees (Lindert et al., 2009; Turrini, et al., 2017). These findings can be explained by the
psychological impacts of pre-flight exposure to war, persecution and violence, the displacement
experience and post-migration struggles in host countries (Knipscheer & Kleber, 2006; Miller &
Rasmussen, 2010).
Recently, research on refugee mental health has shifted from the concentration on pre-
migration trauma towards a focus on post-migration stressors (Davidson et al., 2008; Silove et al.,
2017) and on how these stressors might interplay with and exacerbate previous traumas and
suffering (Cleveland et al., 2014). Post-migration stressors include experiences of culture shock and
cultural bereavement (Bhugra & Becker, 2005; Eisenbruch, 1991; Oberg, 1960), social isolation
(Miller & Rasmussen, 2010), discrimination (Beiser & Hou, 2016), prolonged detention, tedious
asylum application procedures, insecure residency status (Comtesse & Rosner, 2019; Davidson et
al., 2008), financial troubles (Bogic et al., 2012), limited access to services and unemployment
(Silove et al., 2017).
The post-migration stressors are primarily shaped by the juristic, structural, cultural and
societal conditions of the host countries which vary considerably from country to country
(Davidson et al., 2008). This makes the experiences and suffering of refugees unique in each
context. Furthermore, societal conditions, together with traditions in psychological sciences,
22Displaced people include various groups such as refugees who have been officially recognised as such, asylum-
seekers who are still waiting for a decision on their refugee status and people with humanitarian visas who do not fall
officially under the UN definition of a “refugee”, as for instance many Haitians in Brazil. Nevertheless, the present
article will refer to all of these people as refugees. Firstly, we hope this facilitates easier reading. Secondly, grouping
these very heterogenous people together is based on the assumption that displaced people find themselves in a
comparable predicament that is distinct from that of the general population.
23Throughout the article, the denomination of terms of mental illnesses (e.g. “depressive disorder”) is in accordance
with the respective reference from which the term was taken. Furthermore, the expression “psychological suffering”
is used to allow for the inclusion of a range of experiences and mental states that are considered troubling, confusing
or not perceived to be healthy by the people concerned. This expression was chosen to capture a wider scope of
problems than the designation “mental disorder” would characterise.
125
influence what is considered mentally healthy or pathological (Kirmayer et al., 2015). Meanwhile,
most studies investigating the mental health of refugees in host countries stem from Western and
high-income countries. Some studies have looked at refugee mental health in middle- or low-
income countries such as Bosnia, Uganda and Sudan (see Reed et al., 2012), but there are few
studies on refugees in Latin American countries (Moraes Weintraub, 2012; Teixeira et al., 2013).
Notable exceptions include studies with Colombian refugees in Ecuador (Carrasco García, 2010)
and with Palestinian refugees in Chile (Bijit Abde, 2012). This prevalent selective geographical bias
in psychological research leads to mental health concerns being defined by high-income countries
(Kirmayer & Pedersen, 2014). There is a need to study concepts of pathology, in particular related
to the mental health of refugees, in a greater variety of cultures and contexts (Duden et al., 2020).
Following the suggestion of an inside-out model that prioritises the perspectives of those
underrepresented in research (Gergen et al., 2015; Hall et al., 2016; Syed et al., 2018), the present
study aimed to look at the perspectives of psychologists who treat refugees in Brazil.
In Brazil, by December 2018, the total number of recognised refugees exceeded 11.000
with over 161.000 people still waiting for their asylum claims to be processed. About 80.000 new
applications were submitted in 2018 alone (CONARE, 2019). This represents a considerable
increase in asylum applications in Brazil, inter alia related to the earthquake in Haiti in 2010 and
the humanitarian crisis in Venezuela from 2016 onwards. In 2018, most asylum applications were
received from Venezuelans, followed by Haitians and Cubans. The highest number of official
refugee statuses were granted to Syrians (CONARE, 2019). Brazilian jurisdiction relies on a
comparably broad definition of “refugee” and also allows the possibility of humanitarian visa
(Patarra & Fernandes, 2011). Asylum-seekers are granted a work permit directly after applying for
asylum, and there is no deportation in Brazil (Jubilut, 2006; Leão, 2011). However, there is little
information on the situation and mental health of refugees in Brazil (Moraes Weintraub, 2012;
Teixeira, et al., 2013). The need for such information, and the development of adequate mental
healthcare services, has risen dramatically in recent years (Bógus & Rodrigues, 2011; Bustamante
et al., 2016).
The present study aimed to investigate the experiences of psychologists regarding their
refugee patients’ psychological suffering. We decided to interview professionals as experts due to
our assumption that psychologists who encounter refugees in their daily practise might have special
insight into the mental health and suffering of their patients (Meuser & Nagel, 2009). Investigating
their experiences and knowledge might be a valuable first step for understanding refugee patients’
situation in Brazil and develop appropriate mental healthcare services. We focused on professionals
in Brazil for two main reasons: Firstly, there is a lack of knowledge and research concerning
refugees in Brazil. Secondly, gaining the perspectives of experts from a non-Western country might
126
provide new insights for the discussion on the categorisation of mental disorders (Drožđek, 2007;
Kirmayer, 2001; Summerfield, 1999). Our research design addressed participants’ perspectives as
culturally mediated phenomena located in the Brazilian context, with the aim to understand
“explanatory models” of practitioners (Kleinman, 1980). This concept from medical anthropology
stresses the importance of causal attributions and ethnophysiological theories on illness experience,
but also on treatment response (Kirmayer & Sartorius, 2007; Watters, 2001). In other words, how
psychologists in Brazil think about the suffering of their refugee patients will influence how they
attend to the needs of those patients within the Brazilian context.
Specifically, we formulated the following research questions:
How do psychologists who work with refugees in Brazil experience the psychological suffering of
their patients?
a) How do they describe the suffering?
b) Which mental health disorders and symptoms do they perceive to be most common
among their refugee patients?
Method
Study design
This article forms part of a larger study investigating Brazilian approaches to the mental
healthcare of refugees. The focus of the present investigation was how psychologists experience
the psychological suffering of their refugee patients. In order to allow for an in-depth analysis of
psychologists’ perspectives located in the Brazilian socio-political and cultural context, the research
project used qualitative procedures of inquiry resting on a constructivist ontology and a subjectivist
epistemology. The study consisted of semi-structured interviews which were analysed adopting a
consensual qualitative research (CQR) approach.
Participants and procedures

Gatekeepers and contacts to local NGOs were used for recruitment, as well as subsequent
snowball sampling. The ethics committee of the University of Osnabrück gave ethical approval for
the study and informed written consent was obtained from all participants. A semi-structured
interview guideline was developed with the objective of encouraging participants to speak about
their perspectives on their refugee patients’ suffering. It included questions on common
characteristics of participants’ patients such as patients’ country of origin (CoO), questions on
patients’ psychological suffering, symptoms and mental health disorders as well as on psychologists’
127
use of diagnostic manuals and categorical classification of mental disorders (MDC). The latter was
incorporated to allow for a contextualisation of the findings on frequent disorders, as we assumed
that usage of MDC, such as for instance the DSM-5, would influence the way psychologists spoke
about patients’ suffering. The guideline was pilot tested with Brazilian psychologists to ensure the
unambiguity of questions. Between November 2018 and May 2019, semi-structured interviews
were conducted with participants (N = 32) who held a university degree in psychology and had
been working with refugee patients for at least six months (Table 5, on pp 117-118). 44% of the
psychologists were of psychoanalytic orientation, reflecting the often-reported predominance of
this approach among general clinical psychologists in Brazil (González, 2018; Yamamoto, 2012).
Seven of the participants had a migrational background. Most of the participants did not exclusively
attend refugee patients, but also worked with other immigrants and Brazilians.
Interviews lasted between 40 minutes to 2 hours. They were conducted in Portuguese,
either face-to-face at participants’ workplaces (n=19) or via skype (n=13), audio recorded and fully
transcribed. To secure the anonymity of participants, all identifying information was removed, the
names of participants were replaced for codes and locations of practice were collated into regions.
Data analysis
Interview transcripts were analysed focusing on the overt meaning in the data, i.e. what is
said and by whom. CQR (Hill et al., 2005) was adopted as this approach represents a systematic
method to evaluate the representativeness of issues across cases. First, every interview was read
thoroughly and sections related to psychological suffering of refugees were highlighted. The first
author coded highlighted sections line-by-line and developed a hierarchical coding tree by collating
the codes into subthemes, themes and categories. In order to assess the fit of the coding tree, the
first author and two further researchers re-applied it to the interview transcripts independently and
subsequentially discussed until a consensus about the codes, subthemes, themes, and their
hierarchical structure was found. These steps were carried out in Portuguese (González & Lincoln,
2006). The coding tree was then translated into English, using a bilingual committee (Brislin, 1970).
Next, the whole data set was organised into the English coding tree using the qualitative analysis
software MAXQDA (VERBI-Software, 2020) in order to systematically represent the frequencies
of participants endorsing each theme and subtheme (Table 7 and Table 8). The frequency counts
enable an overview of the presence of each theme in the data set (Malterud, 2001b). Themes were
labelled “general” if they were endorsed by 31-32 participants, “typical” if they applied to 16-30
cases, “variant” for less than 16 but at least five cases, and “rare” if endorsed by only one to four
participants (Hill et al., 2005).
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Researchers’ positionality
The study’s principal investigator who conducted the interviews and served as the primary
coder is a PhD candidate in cultural psychology. Being of German origin, she gained awareness for
challenges in post-migration settings through her own experiences of migration and academic
interests in refugee studies. The fact that she is of German nationality might have, in regard to the
history of colonisation (González & Lincoln, 2006), impacted the extent to which participants felt
at ease to articulate their perspectives. Yet, the principal investigator had worked for an extended
period of time among psychologists in Brazil and was, thus, familiar with styles of communication
and interaction in this context. Moreover, the other two coders of the study were Brazilian clinical
psychologists which improves the likelihood that the manner in which psychologists in Brazil speak
about psychological suffering was captured accurately. All three researchers have extensive
experience using qualitative methods of inquiry. Informed by the literature on refugee mental
health, the researchers expected participants to highlight PTSD, depression and anxiety as common
mental health problems in their patients.
Results and Discussion
Refugee patients’ backgrounds

Table 6
Patients’ countries of origin as reported by psychologists
Frequency of mentioning Country of origin of patient (# participants mentioning)
Typical: mentioned by 16-30 Venezuela (23), Haiti (18)
Variant: mentioned by 5-15 Syria (14), Colombia (14), Congo (9), Argentina (8), Angola (7),
Uruguay (5)
Rare: mentioned by 2-4 Guinea (4), Cuba (4), Paraguay (4), Bolivia (4), Capo Verde (3),
Nigeria (3), Peru (3), Mozambique (2), Mali (2), Chile (2), Senegal
(2)
Others: mentioned by a single Afghanistan, Barbados, Benin, Burkina Faso, Burundi,
participant only Cameroon, El Salvador, Ethiopia, Eritrea, Equatorial Guinea,
Filipins, Ghana, Guinea-Bissau, Ivory Coast, Kenia, Lebanon,
Liberia, Libya, Morocco, Palestine, Russia, Togo, Ukraine
Note. This table includes all the nationalities of patients as mentioned by participants, independently of
their immigrational or asylum status.
In order to contextualise the findings on patients’ suffering, psychologists were asked to

name the country of origin (CoO) of their patients as well as additional characteristics they deemed
important. In doing so, participants did not distinguish between patients’ official immigration or
asylum status. Thus, the CoOs reported here are of diverse immigrants, including refugees and
129
asylum-seekers. In sum, participants named 42 different CoOs (see Table 6, Figures 11 and 12).
Most frequently mentioned CoOs were Venezuela, Haiti, Syria, and Colombia. Other frequently
mentioned characteristics of patients were pregnant women or single mothers, lesbian, gay,
bisexual, transgender, and queer people.
Figure 11
Number of psychologists mentioning the respective country of origin of their patients
25
20
15
10
Figure 12
Map showing countries of origin of patients. Colour intensity indicates the number of psychologists mentioning the
respective country.
a) How do psychologists describe the suffering of their refugee patients?

The following section synthesises in four categories what psychologists perceived to
constitute the psychological suffering in their refugee patients (Table 7). Figure 13 displays these
categories as interlinked: Currently, the refugee finds herself in a context of post-migration
130
difficulties (upper part of the figure), her life was ruptured by the flight (zig-zag-line), the
situation in the CoO is still present for her (forming the base of the figure) and traumatic
experiences transcend the CoO, the flight as well as the post-migration situation
I Post migration situation
All participants stressed how the post-migration context causes substantial suffering in
refugee patients. This category took up the most considerable portion of all interview transcripts.
The following factors were perceived as particularly impactful for patients:
Hostile attitudes, Intolerance & Rights Violations
There is suffering for not being recognized by the other. We have many refugees here in Brazil who are
Black, who come from African countries or Haiti. Blacks suffer a lot from racism. Racism is very strong
here. They tell me: “What do I do if I walk on the street, people start walking very fast, they don't stay on
my side.” That creates suffering. (P15, Psychoanalysis, Age: 41, South)
All participants mentioned that their patients were suffering from experiencing hostile attitudes
and intolerance, in particular by being subject to xenophobia, discrimination, racism, LGBTQ-
phobia, as well as not feeling recognised by society or objectified as a refugee. Variant participants
also described the human rights violations their patients were experiencing in Brazil, including
physical mistreatment, (sexual) abuse and slavery work.
Discrimination and xenophobia have been described as major obstacles for the integration
of refugees in Brazil and as strongly related to the struggle of finding employment (Moreira &
Baeninger, 2010). Internationally, experiencing discrimination in host countries has been found to
greatly impact the mental health of refugees (Bogic et al., 2012), sometimes even more than pre-
migratory trauma (Beiser & Hou, 2016).
Isolation
Isolation was another factor participants typically saw as part of the suffering of patients:
“[…] a state of complete loneliness. She feels disconnected from people. She feels that no one will understand her.
And she feels that she won't understand anyone” (P9, Ethnopsychiatry, Age: 28, South). Psychologists
described patients’ feelings of loneliness and not-belonging and highlighted the fact that patients
often suffered due to being separated from their families. Two participants mentioned that refugee
patients had very fragile networks in their new context.
Social isolation has been described as a major stressor in post-migration settings (Miller &
Rasmussen, 2011). Eisenbruch (1991) integrated the loss of social networks and of a sense of
belonging in the concept of “cultural bereavement” which he considered characteristic of forced
131
displacement (e.g. Bhugra & Becker, 2005). Reinforcing this, others have found associations
between the well-being of displaced people and the reconstruction of social networks and a feeling
of community (Summerfield, 1999).
Cultural adaptation
As a further variant factor of suffering in the post-migration situation, processes of cultural
adaptation were described. Participants mentioned the patients’ struggles with integrating into
Brazilian society, experiencing cultural shocks and finding it hard to build relationships with
Brazilians: “They report a lot of difficulty in establishing ties with people here” (P23, Psychoanalysis, Age: 60,
Southeast). Together with feelings of homesickness these struggles contributed to the sense of
isolation in patients. Furthermore, psychologists saw some of their patients as coming into conflict
with their culture of origin.
The latter may, as research suggests, be particularly impactful in individuals with families
and cause intergenerational conflicts since family members can differ in their speed and way of
acculturating (Drožđek, 2007; Leyendecker, et al., 2018). There have been inconsistent results in
the literature regarding the relationship of acculturation and mental health (Kartal & Kiropoulos,
2016), but often cultural adaption is viewed as a cause of substantial distress in immigrants
(Knipscheer & Kleber, 2006; Martins-Borges, 2013, 2017).
Figure 13
Categories of suffering. Traumatic experiences are represented as transcending the CoO, the flight as well as
the post-migration situation
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Table 7
Categories of suffering
Category Theme Subtheme Frequency Region
(P/C)
Post- Intolerance, Xenophobia Variant (14/23) All
migration hostile attitudes & Discrimination Variant (15/18) All
situation violations Racism Variant (12/15) S, SE
Not being recognised by Variant (10/14) S, SE
society
Rights violations Variant (10/14) N, S
Being objectified as refugee Variant (6/10) S, SE
LGBTI-phobia Rare (4/6) N, S
Isolation Loneliness Variant (12/26) All
Family separation Variant (14/24) All
Feeling of not belonging Variant (9/17) All
Fragile networks Rare (2/2) S
Cultural Cultural shock Variant (15/23) All
adaptation Conflicts with own culture Variant (10/21) S, SE
Difficulties of integration Variant (13/25) All
Homesickness Variant (6/9) N, S
Precarious Precarious economic Typical (22/44) All
situation situation
Insecurity of future Variant (7/11) All
Dependency & Helplessness Variant (13/22) S, SE
Hunger & thirst Variant (12/18) All
Living on street Variant (11/15) N, S
Other housing problems Variant (9/13) All
Traumatic Violence Sexual violence Variant (11/18) All
experiences Domestic violence Variant (10/15) All
Other violence Variant (15/20) All
Torture Rare (1/1) S
War experiences Variant (6/8) S
See people dying Variant (7/7) S, SE
Being persecuted Variant (5/7) S, SE
Robbery Variant (6/10) All
Surviving an Variant (6/6) S, SE
earthquake
Victim of human Rare (4/5) N, S
trafficking
Crossing Amazon Rare (4/5) S
forest
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Table 7 (cont.)
Categories of Suffering
Category Theme Subtheme Frequency Region
(P/C)
Flight as life Flight as Typical (17/31) All
rupture involuntary
Flight as Rare (4/5) S
existential crisis
Experiences of Generically mentioneda Typical (23/73) S, SE
loss Loss of social function Variant (13/20) All
Loss of culture & language Variant (11/23) All
Loss of relations Variant (10/11) All
Loss of identity Variant (5/9) All
Loss of place Variant (5/5) All
Material loss Rare (2/2) S
Current Expectations from Variant (8/14) All
Situation in family
CoO Unstable CoO Variant (5/15) All
Guilt of surviving Variant (6/8) All
No reparation for Rare (2/2) S
violations
Note. North = North, S = South, SE = Southeast
Precarious situation
The precarious nature of the patients’ context was typically perceived as a further aspect of
refugees’ suffering: “the precariousness of his life made him feel paralyzed and unable to act.” (P10,
Community/Social Psychology, Age: 27, South). Variant participants described patients fearing for
basic needs, experiencing hunger or living on the street. Furthermore, participants typically
highlighted the economic instability and financial troubles of patients due to a lack of stable
employment and financial support structures. Variant psychologists mentioned that the precarious
situation evoked feelings of helplessness and humiliation in many refugees. Participants also
stressed the impact of future insecurity on patients:
The greatest suffering is the uncertainty. They are not ‘refugees’ when they arrive. They are ‘asylum-seekers’,
a totally preliminary and provisional situation that can last three to five years. This reinforces the liminal
character of migration... being in and out... which makes it impossible to build long-term plans. (P3,
Community/Social Psychology, Age: 61, Southeast)
A strong association between social inequality, poverty and mental health disorders has
been stressed for the general population in Brazil (Silva & Santana Santana, 2012). Concerning
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refugees, employment and economic stability have been found highly important for good health
outcomes (Bogic et al., 2012; Lindert et al., 2009; Knipscheer & Kleber, 2006). The effect of future
instability due to tedious asylum procedures and temporary visa on the mental health of asylum-
seekers is an issue of international concern (Comtesse & Rosner, 2019; Davidson, et al., 2008). The
fact that not all participants mentioned this as part of their patients’ suffering may be explained by
the asylum procedures in Brazil: Even though refugee applications are only processed slowly,
detention and deportation do not exist (Jubilut, 2006; Leão, 2011), which are the two aspects that
have been most strongly associated with future insecurities (Davidson et al., 2008; Momartin et al.,
2006).
II. Traumatic experiences
Most participants talked in some form about traumatic experiences in relation to the
suffering of their patients. Patients’ traumas included experiences of war, surviving an earthquake,
violence and human trafficking, seeing people dying, being persecuted, robbed, and crossing the
Amazon forest:
She entered the Amazon forest and spent days on a boat in a river with crocodiles and with others who
assaulted her. In this country, on her first stop after Cuba, she worked in slavery-like conditions, she was
even locked-in at her work, and she had to escape. (P12, Ethnopsychiatry, Age: 27, South)
The types of trauma experienced depended on patients’ trajectories and their CoOs. For instance,
psychologists who attended mainly Haitians often described the impacts of surviving an
earthquake.
III. Flight as life rupture
A common issue is grief. Grief in relation to the country, to the culture, to the recognition of identity. To
their life project, that was abruptly interrupted.” (P24, Ehnopsychiatry, Age: 33, South).
Most psychologists perceived a life rupture due to the involuntary flight as part of the
suffering of their patients. The flight came with many losses that sometimes lead to the experience
of existential crisis.Leaving one’s home involuntarily without preparation for the ruptures that this
flight will cause has been described as a risk factor for mental health (Martins-Borges, 2013).
Research has shown that experiencing loss, such as of one’s home and the sense of social belonging
and connection to a land and its symbols is associated with refugees’ mental health outcomes
(Davidson, et al., 2008). The loss of social belonging also forms an essential element of the concept
of cultural bereavement (Drožđek, 2007; Eisenbruch, 1991).
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IV. Current situation in country of origin (CoO)
Finally, psychologists suggested patients’ suffering was dependant on what was happening
in their CoO. First, they linked patients’ distress to the expectations from relatives that remained
in the CoO. Second, patients suffered when the situation in their CoO was still unstable, dangerous
and difficult for those who had stayed: “First of all there is the family left behind in Venezuela. I hear a lot
that it’s like a type of guilt: ‘I am here eating, I am here sleeping, and my family is starving on the street.’” (P22,
Psychoanalysis, Age: 43, Southeast). Some patients were described to be constantly worrying about
the well-being of their relatives in the CoO and to be feeling guilty for surviving and leaving people
behind. Furthermore, two psychologists saw the fact that patients did not receive reparations from
their CoO for violations they had experienced as impeding the healing process.
Many of the CoOs of participants’ patients, such as Venezuela and Haiti, continue in
precarious situation of violence, famine and misery (Oliveira et al., 2019). The literature shows that
refugees from countries whose conflicts are still unresolved have worse mental health outcomes
(Porter & Haslam, 2005) and a sort of “survivor guilt” has been reported as a common phenomenon
among refugees (Eisenbruch, 1991; Martins-Borges, 2013).
b) Which mental health disorders and symptoms do psychologists perceive

to be most common among their refugee patients?
The following section focuses on the mental disorders and symptoms participants most
commonly perceived in their patients (see Table 8 and Figure 14). However, and in order to
contextualise these results, we first report on whether and in which way participants made use of
mental disorder classifications (MDC).
Table 8
Disorders and symptoms mentioned by psychologists organised according to the DSM-5 (American Psychiatric Association,
2013)
Disorders Section Symptoms Frequency Region Total
(#P) (#P)
Depressive Diagnosis : Major
a - Variant (11) All Typical
Disorders Depressive Disorder (22)
Symptoms, genericb - Variant (8) N, S
Symptoms, specificc Sadness Variant (8) All
Suicidal ideation Variant (7) All
Tearfulness/crying Variant (6) All
Diminished Rare (3) N, S
interest /Apathy
Social withdrawal Rare (1) S
Poor Rare (1) S
concentration
Low self-esteem Rare (1) S
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Table 8
Disorders and symptoms mentioned by psychologists organised according to the DSM-5 (American Psychiatric Association,
2013)
Disorders Section Symptoms Frequency Region Total
(#P) (#P)
Fatigue Rare (1) S
Hopelessness Rare (3) N, S
Anxiety Diagnosis: Generalized - Variant (11) N, S Typical
Disorders Anxiety Disorder (17)
Symptoms, generic - Variant (6) S
Symptoms, specific Excessive fear Rare (3) N, S
Panic attacks Variant (6) All
Posttraumatic Diagnosis: PTSD - Variant (5) All Variant

Stress Symptoms, generic - Rare (3) All (10)
Disorder Symptoms, specific Dissociative Rare (3) S
(PTSD) reactions
(flashbacks)
Somatic Diagnosis - - - Variant
Symptom and Symptoms, generic - Variant (5) N, S (7)
Related Symptoms, specific Abdominal pain Rare (3) S
Disorders Headache Rare (3) S
Backache Rare (1) S
Chest pressure Rare (1) S
Schizophrenia Diagnosis: Psychotic - Rare (4) S, SE Variant
Spectrum and Disorders (6)
Other Symptoms, specific Delusion of Rare (1) S
Psychotic persecution
Disorders Hearing voices Rare (1) N
Substance- Diagnosis: Generic - Rare (3) All
Related and
Addictive
Disorders
Autism Diagnosis - Rare (1) N
Spectrum
Disorder
Adjustment Diagnosis: Adjustment - Rare (1) N
Disorder Disorder
Other Sleep disturbances Variant (5) N, S
categories and Aggressivity Rare (1) S
symptoms d Impulsivity Rare (1) S
Grief Variant (12) All (12)
Severe Stress Variant (5) N, S (5)
Note. a The term “diagnosis” is indicated when psychologists explicitly mentioned the respective diagnostic category.
b The term “generic” is indicated to show the number of psychologists mentioning general symptoms of a disorder
(e.g. “depressive symptoms”) rather than specifying them further.

c “Specific” refers to the specific symptoms of a disorder described by participants.
d Categories and Symptoms which are either not listed in the DSM-5, but were highlighted by participants, or which
were not mentioned uniquely in relation to one specific disorder.
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Use of mental disorder classifications

Prevailing among participants were critiques of MDCs with 18 stating they did not use
psychiatric diagnostic manuals such as the DSM-5 at all.
I don't think diagnostics have any function. Because they're Western diagnostics. If I am talking about
understanding the constitution of a subject in a cultural dimension, the way he suffers, and what he presents
as suffering, is also a narrative of his culture. And who made the diagnoses were Westerners. From a
biomedical perspective.(P6, Ethnopsychiatry, Age: 28, South)
I don't work with diagnostics at all. I think they suit the pharmaceutical industry a lot because they frame
the subject by his symptom […] that human part of medicine, in the case of these diagnostic manuals, has
been lost. Psychiatrists, for example, have become prescribers of pain medication. There is no ‘listening’
anymore. (P17, Psychoanalysis, Age: 47 years, South)
Certainly, these opinions might also reflect the fact that of the participants 44 % followed
Psychoanalytic/-dynamic, 25 % Ethnopsychiatry and 16 % Community, Social or Systemic
approaches (Table 5, pp. 117-118) – therapeutic orientations which do not place their emphasis on
diagnostic categories (e.g. Guzder, 2014; Wolitzky, 2020). Some psychologists indicated the use of
diagnostic strategies, but rather than applying categorical manuals such as the DSM-5, they were
oriented towards psychoanalytic structural diagnostic or the axis of DSM-IV. These approaches
seemed more flexible, continuous and more appropriate to them. The participants who made use
of manuals such as the DSM-5 (n=14), indicated employing them carefully and mostly in order to
communicate with other professionals.
A critical use of Western psychiatric diagnostic manuals is not uncommon in Latin
American countries (Parra, 2013). Internationally, critiques of these manuals have been made,
especially concerning their universal applicability (Drožđek, 2007; Summerfield, 1999). Some have
also posed the more general question if MDC necessarily leads to an improvement in our
understanding of effective interventions (Kirmayer & Sartorius, 2007). In line with many of the
participants of the present study, Aveline (2005, p. 158) argues, that the categorical perspective of
psychological suffering often does not fit the “problems in living” of patients. To a large extent the
interviewed psychologists embraced the idea that the focus on classified disorders was insufficient
to guide their practice, as patients struggled with the “social suffering” discussed in the previous
section, i.e. contextual predicaments stemming e.g. from experiencing racism, not necessarily from
psychiatric disorders (Guzder, 2014; Kleinman et al., 1997).
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I haven’t identified depressive cases. The point is, there are cases of sadness, but if you do a little more
analysis, you realize that it’s a sadness of the whole process they are experiencing in their lives at the
moment. (P16, Community/Social Psychology, Age: 29, South).
Mental health disorders and symptoms

Despite critiques of MDCs, all psychologists participated in a description of the most
common symptoms and disorders of their refugee patients. The descriptions are elaborated here
and represented in Figure 14 and Table 8.
Figure 14
Most frequently mentioned symptoms or states
Anxiety symptoms
20
15
Somatic symptoms Depressive symptoms
10
5
0
Sleep disturbances Grief
Severe stress PTSD symptoms
Symptoms/States
Note. The number indicates the sum of psychologists who referred to the
respective symptom or state.
Depressive disorders and symptoms
Typically, psychologists mentioned depressive disorders and symptoms as common among

their patients. Described depressive symptoms included constant crying, sadness and apathy. Three
participants also referred to a deep despair in patients which they perceived as an existential
hopelessness. Furthermore, suicidal ideation was often mentioned in combination with depression.
Internationally, depression has been reported with high prevalence rates among refugees
(Lindert et al., 2009). In Brazil, a study of Haitian immigrants yielded that depressive symptoms
were in the clinical range in 10.6% of participants (Brunnet et al., 2018). A study of Bolivian
immigrants in São Paulo indicated the high probability of a mental disorder in more than half of
the participants, with depressive and anxiety symptoms having the highest prevalence (Bustamante-
Ugarte, et al., 2019).
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However, many participants of the present study questioned the distinction between
depressive disorder and grief. 12 of the interviewed psychologists explicitly stated they preferred
to talk in terms of grief as opposed to depressive disorder and to consider their patients’ mental
states, which resembled depressive phases, to be normal reactions to the many losses the refugees
had faced.
The refugee suffers from grief. From a succession of bereavements. The refugee’s suffering revolves around
loss. The loss of a known place, the loss of a group of people, of relationships, the loss of a social function.
So, I think in terms of psychic suffering the most striking one is loss and grief. (P9, Ethnopsychiatry, Age:
28, South)
In the literature there has been a resurgence of interest in the construct of grief, especially
concerning refugee patients (Comtesse & Rosner, 2019; Momartin et al., 2004; Silove et al., 2017),
since loss is such a common experience among refugees and linked to their mental health outcomes
(Davidson et al., 2008).
Anxiety disorders and symptoms
Typically, psychologists also described anxiety symptoms and disorders as common in their
refugee patients:
The most common psychological suffering.... Very high anxiety. Depression. Absurd. Panic attacks. […]
Anxiety and panic because they find themselves in a dangerous situation and are always alert. And that
means stress as well. They are always afraid that somebody could rob them, the family is starving and in
need of them in Venezuela. (P1, Existential/Humanistic Psychology, Age: 31, North)
Research has found heightened levels of anxiety in asylum-seekers (Silove et al., 1997).
Lindert et al.’s (2009) meta-analysis showed a combined anxiety prevalence rate of 40% in refugees
and more recently, Turrini et al. (2017) reported that anxiety and depression in refugees were at
least as frequent as PTSD and affected on average one out of three refugees. Presumably, anxiety
states result from refugees’ past experience, but also from the insecurity and instability in their
postmigration situation: “Anxiety disorders are very present. But for complex reasons, not for certain permanent
core beliefs, but due to the external stress that is permanent.” (P20, Cognitive-behavioural Psychology, Age:
43, South). In the case of Brazil, one might question if heightened anxiety is specific to refugees or
also common in the general population and a reflection of a widespread sense of political, economic
and personal insecurity. For instance, in São Paulo anxiety disorders were found to affect almost
20 % of the general population (Andrade et al., 2012).
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Posttraumatic Stress Disorder (PTSD)
Ten participants spoke of PTSD or related symptoms among their patients: “There's
posttraumatic stress which we end up working with a lot. You see a lot of it. Posttraumatic stress due to displacement,
due to violence.” (P1, Existential/humanistic Psychology, Age: 31, North). At the same time, 29
psychologists used the word “traumatic” when describing their patients’ experiences: “Many were
raped and robbed on their way. They got here only with their cloths on their body- The experience from there to here
is traumatic for almost everybody.” (P29, Psychoanalysis, Age: 23, North).
The finding that most participants described refugees’ traumas but relatively few mentioned
PTSD might, firstly, be due to an epistemological difference in participants’ concepts of trauma
and the concept underlying the PTSD diagnosis. When participants were invited to explain their
understanding of trauma, most psychologists defined it as an event that did not have a psychic
representation and was “unbearable to tell”. This demonstrates a psychoanalytic understanding of
trauma (Levine, 2014). A second explanation might be that, even though, robust associations have
been made between pre-flight trauma and the mental health of refugees (Davidson et al., 2008;
Silove et al., 1997) and refugees show higher rates of PTSD than the general population (Fazel et
al., 2005), most people who have survived traumas do not develop PTSD (Bisson et al., 2015).
Furthermore, traumas linked to profound losses might, in the long term, rather evoke depressive
than PTSD symptoms (Momartin et al., 2004). Finally, a closer analysis of the transcripts showed
that, in relation to the aforementioned critical attitude towards MDC, many participants were
reluctant to use the PTSD category as they worried that this would reduce patients’ suffering to
past events and turn it into an individualised and “medical” problem, thus neglecting its socio-
political dimension: “Of course, trauma means that the subject has experienced a terrible traumatic scene. I'm
not saying otherwise. I am saying that the socio-political situation promotes trauma and is something that stifles the
subject in various ways.” (P27, Psychoanalysis, Age: 33, Southeast)
As with most diagnostic categories, the concept of PTSD is a product of Euro-North-
American culture, context and history (Kirmayer et al., 2015), but the discourse around it has
reached diverse cultural realties globally (Argenti-Pillen, 2000). One might wonder if participants’
critique of the concept of PTSD, i.e. implying an individualisation of trauma, could be related to
the recent history of dictatorship in Brazil which involved experiences of collective traumas
(Kevers et al., 2016). However, the argument, that PTSD is too much focused on past traumas and
disregards the socio-political context in which traumas occur, has been used internationally, too, as
one aspect of the considerable critique of PTSD (Drožđek, 2007; Kevers et al., 2016, Summerfield,
1999). Some authors state this focus implies neglecting the complexity of the refugee situation and
so missing out on the opportunity to better mental health outcomes in refugees by changing present
conditions in host countries (Watters, 2001). This was also stressed by the participants in the
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current study who, in line with Cleveland et al. (2014), consistently brought up the present post-
migration situation as interplaying and exacerbating past traumas:
In the case of the Syrians, we think that we will work with war traumas. But none of them ask for trauma
care in the sense we imagine. All of them have other challenges, especially the daily challenge of living as a
refugee here in Brazil. (P19, Systemic Psychology, Age: 30, South)
Other mental disorders and symptoms
Other mental health conditions described by more than one psychologist included somatic
symptoms, psychotic disorders and symptoms, severe stress, sleep disturbances and substance
abuse: “There are a lot of cases of alcoholism, in women too.” (P30, Existential/humanistic Psychology, Age: 40,
North)
Most of these disorders and symptoms have been described in previous studies concerning
the mental health of refugee patients (Silove et al., 2017). For instance, a number of studies has
linked PTSD symptoms to psychotic symptoms in refugees (Nygaard et al., 2017) and reports of
somatic symptoms are common among immigrant, but also among most general patients suffering
from depression or anxiety (Kirmayer, 2001).
Limitations and suggestions for future research

The results of the present study have to be considered in light of certain limitations. Firstly,
it is important to note that participants reported not on refugees in general, but on their refugee
patients, i.e. people who seek psychological help as they find themselves in troubling states. To
obtain a broader picture of the mental health of refugees in Brazil, future studies are needed that
focus on refugees outside of clinical settings.
Secondly, findings represent the subjective evaluations of psychologists who treat refugees
in Brazil and do not represent quantifiable or generalisable data. For instance, participants might
have been more likely to report on extreme cases when asked to describe their patients’
psychological suffering. However, as the first study investigating the suffering of refugee patients
across Brazilian states, the results provide valuable insights into common social and mental health
problems faced by this group and a base for further epidemiological and quantitative studies.
Potentially lower rates of PTSD diagnosis in Brazil for example, might also result from
professionals’ critical attitude towards mental health categorisation and the PTSD concept.
Finally, this study focused on psychologists’ experiences in treating heterogenous patients
from various countries (see Table 6) with diverse reasons for migration, heterogenous experiences
of flight and post-migration stressors, and varying lengths of stay in Brazil. These factors and their
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complex interaction may play a crucial role in shaping patients’ mental health (Turrini et al., 2017).
Also, even though participants were asked to report on their refugee patients, it is unclear if their
descriptions only related to people with the respective official asylum status. Many of the
psychologists also treated general immigrants and may not have differentiated between patients in
relation to their immigration status when reporting on their suffering. This, as well as the diverse
interview settings ranging from the South to the extreme North of Brazil, is likely to have impacted
participants’ descriptions of their patients’ suffering (Andrade et al., 2012). However, the analysis
of the data did not show any major differences in perspectives on patients’ suffering related to
location of practise (Table 7), except for traumatic war experiences which were only described by
psychologists in the South and Southeast. This might be explained by the fact that there are more
Syrians applying for asylum in these regions (CONARE, 2019). Patients in the North came almost
exclusively from Venezuela, where there is a humanitarian crisis (CONARE, 2019), but not a
situation of war as in Syria. Further studies could explore the differences in suffering related to
diverging asylum status and psychologists’ location of work in more detail.
Conclusion
To our knowledge, this study is the first to investigate psychologists’ perspectives on the
suffering of their refugee patients in diverse Brazilian states. It confirms previous findings
highlighting depression and anxiety as common conditions among refugee patients (Lindert et al.,
2009), but also supports concepts such as prolonged grief (Comtesse & Rosner, 2019; Momartin,
et al., 2004) and cultural bereavement (Eisenbruch, 1991) as valuable alternatives to common
mental disorder classifications in refugees. Additionally, the present study provides evidence for a
prevailing critical perspective on mental disorder classifications such as the DSM-5 among
psychologists in Brazil. Many of the participants thought of the suffering of refugee patients in
relation to their social and political context and post-migration situation, rather than in relation to
specific diagnostic categories. This reinforces the call to acknowledge the socio-political suffering
of refugees (Drožđek, 2007; Silva Machado, et al., 2019) and increases the importance of strategies
that, in order to foster the mental health of refugees, address current stressors in post-migration
settings, such as discrimination (Duden et al., 2020).
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Chapter 6
Psychologists’ Perspectives on Providing
Psychological Care for Refugees in Brazil
Gesa Solveig Duden & Lucienne Martins-Borges
Submitted to Counselling Psychology Quarterly

Section II | Chapter 6 Psychological Care for Refugees in Brazil
Abstract
To gain insights into psychologists’ experience of working with refugees in Brazil, semi-structured
interviews with 14 psychologists were conducted and analysed using thematic analysis. Results
show that participants experience operating in a novel, precarious and xenophobic context, which
leads them to move beyond classical psychological work, engage in practical assistance and become
very close to clients. Psychologists report lack of public structures, insufficient competencies and
high levels of fatigue. At the same time, they describe gaining new perspectives and benefiting from
witnessing their clients’ resilience. In terms of facilitators for the work with refugees, participants
point to the importance of psychologists being flexible, authentic, of showing a high frustration
tolerance and of making use of group-based approaches. Participants suggest that, in order to better
refugees’ mental health in Brazil, efforts should focus on adopting a more social perspective in
psychology, developing anti-discrimination campaigns, building policies for refugee’ inclusion and
scaling up investments in mental healthcare in general. Suggestions for future research are made,
as well as for psychologists who work with refugees, such as fostering a more collectivity-focused
and contextual understanding of mental health.
Keywords: Refugees, Transcultural Mental Healthcare, Latin America, Experts’ Perspectives,

Structural Competence
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Introduction
Mental health support for displaced people has turned into a field of international interest
(Barrington & Shakespeare-Finch, 2013) and the number of people who have been forced from
home has risen to 80 million worldwide (UNHCR, 2020). Displaced people are very heterogenous
and include internally displaced people, stateless people, asylum-seekers, who are waiting for their
asylum claim to be processed, and refugees, who have received official asylum status in a host
country (UNHCR, 2020a). Throughout this article the term “refugee” will be used, independently
of the official asylum status, to refer to people who were forced to leave their country due to diverse
reasons such as war, violence, persecution or inhuman living conditions. Certainly, not all refugees
develop mental health problems. At the same time, higher rates of mental disorders and symptoms
of psychological distress, compared to the general populations in host countries, are common
following the experiences of violence, displacement and challenges in resettlement (Bäärnhielm et
al., 2017; Fazel et al., 2005).
A number of investigations have attempted to shed light on effective interventions for
refugees suffering from mental health problems. For instance, two recent metasyntheses (Duden
et al., 2020; Karageorge et al., 2017) identified, that refugee clients themselves and psychological
professionals found the adaptation of therapeutic approaches to clients’ complex needs most
helpful. Especially the use of psycho-social work and advocacy have been considered strategies to
recognise and adapt to refugee clients’ socio-political context (Drožđek, 2007; Metzl & Hansen,
2014; Kronsteiner, 2017; Watters, 2001). In the metasyntheses, professionals who listened to
refugee clients, avoided pre-assumption about their needs and assisted them with practical matters
were regarded as supportive by clients. On the other hand, psychologists who stuck to “classic”
therapeutic approaches were frequently criticised as not mindful about the particularities of refugee
clients’ situation. Therapeutic advice regarding sleep hygiene for example, was perceived as
inappropriate and de-contextualised (Duden et al., 2020). Moreover, the importance of cultural
sensitivity was emphasised, as well as the high impact this type of work can have on professionals’
own mental health (Barrington & Shakespeare-Finch, 2013). To better understand the needs and
processes involved in the mental healthcare for refugees, the two metasyntheses, along with other
authors (Watters, 2001), underscored the importance of methodologies addressing the perspectives
of insiders, namely of professionals and of refugee clients.
However, both syntheses, in keeping with general trends in the field of psychology (Syed
et al., 2018), investigated mental health interventions for refugees in Western Europe, Australia and
North America and thus, addressed only on a small part of the world receiving refugees (Duden et
al., 2020). This selective focus leads to concerns being framed by institutions from wealthy
146
countries and insufficient attention being paid to “locally defined priorities” (Kirmayer & Pedersen,
2014, p. 76). What is more, geographical location, societal context, culture and traditions in the
psychological sciences influence constructions of mental health, as well as forms of healing
(Kirmayer, 2004). Hence, there seems to be a need to explore mental healthcare approaches and
settings in a greater variety of countries. Although mental health support of refugees has received
increasing attention in the scientific literature (Duden et al., 2020; Barrington & Shakespeare-Finch,
2014; Karageorge et al., 2017; Murray et al., 2010), to our knowledge, no prior research has focused
on the experience of psychologists working with refugees in Brazil. The present study aimed to fill
this gap by investigating psychologists’ experiences of their psychological work with refugees in the
Brazilian context.
Following its re-democratisation, Brazil has turned into a receiver country of refugees with
specific laws for refugee protection and a considerably broad definition of the concept of refugee
(Jubilut, 2006). In 2018 only, about 80.000 applications for asylum were submitted in Brazil. Even
though the number is relatively low considering the total number of asylum-seekers worldwide of
3,5 million in 2018 (CONARE, 2019), or compared to the 185.853 total asylum applications in
Germany in the same year24 (BAMF, 2019), for Brazil they represent a considerable increase in
asylum applications. In 2019, the number of displaced people (asylum-seekers and refugees taken
together) was 363.683 in Brazil, compared to for instance, 202.562 in Canada, 511.601 in France,
936.164 in Lebanon, 1.470.894 in Germany, and 3.907.789 in Turkey (UNHCR, 2020b). Most
asylum applicants in Brazil in 2018 came from Venezuela, Haiti or Cuba (CONARE, 2019). Most
frequently, Syrians received official refugee status in Brazil in 2018. In total, Syrians formed 40%
of the recognised refugees from 2011 to 2018 in Brazil, followed by Palestinians and refugees from
the Democratic Republic of Congo (CONARE, 2019).
Meanwhile, little is known about the situation of refugees in Brazil in general, and about
their mental healthcare more specifically (Teixeira et al., 2013). The Public Brazilian Unified Health
System (SUS) aims to enable everyone, including refugees, to access free universal healthcare (Paim
et al., 2011). Even though its creation has improved the availability of mental healthcare services,
many challenges remain, particularly since the recent freeze in the spending for mental healthcare
(Doniec et al., 2018). Specialised services for refugees are still very rare (Bógus & Rodrigues, 2011;
Moreira & Baeninger, 2010), but increasingly needed, especially since the earthquake in Haiti in
24 Meanwhile, caution is needed in the comparison of these numbers, as asylum application procedures, and definitions
of “refugees”, asylum-seekers” and “immigrants” differ considerably across states. For a better picture please also refer
to numbers regarding officially recognised refugees and regarding people with pending asylum procedures (e.g.
CONARE, 2019; UNHCR, 2020b).
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2010 and the humanitarian crisis in Venezuela from 2016 onwards (CONARE, 2019; Oliveira et
al., 2019; Patarra & Fernandes, 2011). Some psychologists have reacted to this demand and started
to create psychological services for the “acolhimento psicológico” (psychological care) of refugees.
Commonly, these services are offered by volunteers, by non-governmental organisations (NGOs),
or as part of “community-outreach”-projects of universities (Duden & Martins-Borges, 2020;
Jubilut, 2020). The aim of our study was to investigate the perspectives of psychologists working
in these settings in Brazil. More specifically we asked the questions:
1.) How do they experience the working process with refugee clients?
2.) What do they see as negative aspects or barriers in the psychological work?
3.) What do they see as positive aspects or facilitators in the psychological work?
4.) What do they see as necessary changes to better the psychological care of refugees
in Brazil and ultimately refugee clients’ mental health?
Method
Study design, procedure and participants

This study is rooted in a subjectivist epistemology and applies qualitative methods of
inquiry. The current article results from a larger study exploring the mental healthcare of refugees
in Brazil. The part presented here focuses on the perspectives of psychologists who work in the
“acolhimento psicológico” (psychological care) of refugees. “Acolhimento psicológico” is a
concept and intervention strategy in Brazilian mental healthcare. It involves the reception of people
with psychological concerns and the provision of a space for listening to and bonding with clients
and accompanying them in the process of improving their mental well-being (Ministério da Saúde,
2010). Thus, eligibility criteria for participants were a university degree in psychology (minimum:
“graduação”, a 5-year university education degree according to the Brazilian national curriculum)
and at least one-year experience in working psychologically with refugees. Meanwhile, only
participants were included in this study who worked in the “acolhimento psicológico” of refugee
clients, and who did not provide psychotherapy. Recruitment strategies included the use of
gatekeepers, such as leaders of NGOs and university professors of psychology who are involved
in “community-outreach”-projects, contacting local NGOs and subsequent snowball sampling. All
participants gave their informed written consent. The Ethics Committee of the University of
Osnabrueck approved the study.
In total, 14 psychologists (see Table 9) were interviewed using a semi-structured interview
guideline, which had been pilot tested with Brazilian psychologists to ensure unambiguity of
questions. Eight of the participants held Masters’ degrees, six an undergraduate degree (graduação)
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in psychology. Meanwhile, this difference is a purely academic one in Brazil and does not imply
any differences in terms of licensure or scope of work. To work in psychological care, the
undergraduate degree in psychology is sufficient in Brazil. All participants were registered with a
Regional Council of Psychologists, which constitute the ethics boards of the psychology profession
(for further information on psychology curricula in Brazil please see for instance Rezende, 2014).
The interviews lasted between 40 minutes to two hours and were conducted in Portuguese, either
face-to-face at the workplaces of the participants (n=7) or via skype (n=7). Each interview was
audio recorded and subsequently fully transcribed. For member checking, we sent the interview
transcripts back to participants (Hill, 2012), but did not receive revisions.
Participant names were substituted with codes and other identifying information was
erased. Five participants attended refugee clients in NGOs financed by the church and three
participants in international NGOs. A further three participants worked psychologically with
refugees in community-outreach projects of their universities and two participants worked with
refugee clients voluntarily without receiving payment or having institutional links. Only one of the
participants attended refugee clients in a public institution financed by the state. None of the
psychologists worked exclusively with refugees. Instead, all participants also attended other
immigrants and Brazilians Instead, all participants also attended other immigrants and Brazilians.
Their clients mostly came from Venezuela (mentioned by 12 participants), Haiti (mentioned by
eight) Syria (mentioned by five) and Colombia (mentioned by five participants), but taken together
participants saw clients of over 30 different nationalities.
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Table 9
Characteristics of participating psychologists
Nr. Nationality Age Gender Highest Approach Work as Work with Region of Place of Work Working Languages
degree psychologist, refugees, yrs. Work other than Portuguese1
yrs.
01 Brazilian 31 Woman Graduação2 H-E 2 1 North ACR3 Spanish
02 Peruvian 61 Woman MA S-C 38 20 Southeast ACR Spanish, English, French
03 Brazilian 31 Man Graduação PA-PD 5 5 South Refugee Housing Spanish, English
04 Brazilian 26 Woman Graduação PA-PD 2 2 South Refugee Housing Spanish, English
05 Brazilian 27 Man MA Ethno- 4 1 South ACR Spanish, English
psychiatry
06 Brazilian 27 Woman MA S-C 2 2 North ACR Spanish
07 Brazilian 29 Man Graduação CBT 5 1 South ACR Spanish
08 Brazilian 29 Man MA S-C 4 4 South ACR Spanish, English
09 Brazilian 43 Woman Graduação PA-PD 7 1 South ACR Spanish
10 Brazilian 43 Woman MA CBT 21 1 Southeast ACR -
11 Brazilian 36 Woman MA S-C 10 1 South UCS Spanish, English
12 Brazilian 23 Woman Graduação H-E 2 2 North UCS -
13 Brazilian 40 Woman MA H-E 17 1 North UCS Spanish
14 Brazilian 35 Woman MA PA-PD 13 1 North ACR Spanish, English
Note. ACR = Attendance Centre for Refugees; CBT = Cognitive-Behavioural Therapy; H-E = Humanistic-Existential; MA = Masters’ Degree; PA-PD =
Psychoanalytic, Psychodynamic; S-C = Social & Community; UCS = University Psychological Care Service.
1 All participants also attended patients in Portuguese language.
2 “Graduação” is the Brazilian undergraduate degree which generally takes five years to complete.
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Data analysis
Thematic Analysis (Braun & Clarke, 2006) was used to analyse the explicit (semantic)
meaning in the 14 transcripts. It was chosen as a method, since it integrates a great flexibility in
terms of theoretical and epistemological framework, being a tool to allow for both a reflection of
“reality” (realist, essentialist), and for an unravelling of the surface of “reality” (constructionist,
Braun & Clarke, 2006, p. 9). Our research project aimed to unravel psychologists’ perceptions
(constructionist) and reflect their work realties (realist), thus being located at the midline of the two
poles (critical realism). In such a case, the use of thematic analysis is recommended as a
“contextualist method” (Braun & Clarke, 2006, p. 9). Furthermore, we were already familiar with
this approach, that seeks to describe patterns across qualitative data. We followed the six-step
process suggested by Braun and Clarke (2006) and extended it by counting frequencies of themes
as suggested in Consensual Qualitative Research (CQR, Hill, 2012). Firstly, for familiarisation with
the data, every interview was read thoroughly and a title was given carrying its most prominent
message. Secondly, using a data-based, inductive, analysis style each of the transcripts was coded
line-by-line (Braun & Clarke, 2006). Thirdly, codes were collated and organised into subthemes and
themes, developing a coding tree. All of these steps were undertaken by the first author and in
Portuguese, following the recommendation of Gonzalez and Lincoln (2006). Fourthly, the coding
tree was re-applied to the data by the first author and by two further researchers independently.
This resulted in the reviewing and refining of themes: Researchers discussed and adjusted the fit
of codes, subthemes and themes until consensus was found. Fifthly, the themes and the coding
tree were named and translated into English using back-translation and a bilingual committee
(Brislin, 1970). Sixtly, a draft of the results was produced and reviewed by the researchers. Finally,
as an additional step to thematic analysis, the qualitative analysis software MAXQDA (VERBI-
Software, 2020) was used to organise the entire data set into the, now defined and labelled, themes.
Frequencies of the total of participants who endorsed each theme and subtheme were obtained
(Tables 10-14) and labelled “general” if all participants referred to it, “typical” for at least half and
up to 13 cases, and “variant” for one to 6 participants endorsing the theme (Hill, 2012). Frequency
counts support an overview of the representation of each theme in the data, but do not allow for
inferences of statically valid prevalence (Livingston et al., 2019).
Positionality of the researchers

The first author was the principal investigator of the study and first coder. She is a female,
30-years old doctoral candidate in clinical psychology of German nationality. The second author is
a female, 54-years old professor of clinical psychology and of Brazilian nationality. She and the
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third coder, who is a male, 30-year old psychologist and of Brazilian nationality as well, were
involved in the data analysis by reapplying and assessing the coding tree and discussing its fit. All
three researchers are familiar with the use of qualitative research methods, have lived in Brazil and
gained heightened awareness for post-migration challenges due to their own migration experiences,
academic studies in mental health and culture, as well as their clinical work with refugees in Brazil
and in other countries. For instance, having been migrated to countries which language they did
not speak (e.g. Québec/Canada and Brazil), the authors were well aware of the benefit of
professionals in host countries having various language skills or working with cultural mediators.
Considering their own migration experiences, they also felt that an openness in psychologists to
clients’ cultures of origin should be essential. These experiences might have influenced the results
of the study, for instance by overly highlighting cultural and linguistic differences. For psychologists
who work with refugees rather than immigrants, may not reach the same levels of importance as
structural issues (e.g. basic needs not being met). Meanwhile, the results were also influenced by
the authors’ previous experiences in conducting research on refugees’ mental health concerns.
Reflecting on their positionalities in this regard before conducting the study, authors thought that
psychologists would stress the post-migration difficulties for refugees, as well as the lack of funding
and the current political situation in Brazil as the main obstacles in their work with refugee clients.
In terms of political situation, the interviews took place during an unsettled period in Brazil
– they were conducted from November until May 2019, during which time a new government
came into power. In January 2019, Jair Bolsonaro, a far right, extremely conservative retired military
officer, took office as the Brazilian president (Le Tourneau, 2019). This change in government was
expected to yield consequences for the health and social sectors. Indeed, Bolsonaro’s first acts
involved among other things a change in the conditions under which doctors from the programme
“Mais Médicos” are allowed to practise in Brazil. The programme was introduced under Dilma
Rousseff in 2013 (Oliveira et al., 2015) and the changes weigh heavily on the Brazilian healthcare
provision, since, as a consequence more than 8500 doctors most of them Cubans will potentially
be withdrawn. These doctors have been highly important for Brazilian healthcare particularly in
remote and vulnerable regions (Alves, 2018). There was also a reduction in activities concerning
immigration such as the shutdown of the project “COMIGRAR” (Uebel, 2019) and already in his
second week of office, the new president had withdrawn the country form the global U.N.
migration pact (Londoño, 2019). Furthermore, after we had conducted our last interviews in June
2019, the government undertook important changes in Health, such as diminishing society
participation like the National Board of Psychology (CFP; Marques & Nakatani, 2019).
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Results
In total, 20 themes resulted from the analysis and were placed into five different categories
(see Figure 15) aiming to answer the respective research question:
Question 1: Category A – Experiencing the psychological care
Question 2: Category B – Negative aspects and barriers
Question 3: Category C – Positive aspects and Category D – Facilitators
Question 4: Category E – Necessary changes
Whereas negative aspects and barriers (question 3) formed one single category, positive
aspects of the work experience and facilitators (question 2) were split into two distinct categories.
This decision was based on the fact that, while negative aspects and barriers fully overlapped in the
accounts of participants, positive aspects of the work experience were not simultaneously described
as facilitators for the psychological care work by participants.
Figure 15
Themes relating to the five categories
Category A: Experiencing psychological care

The following themes were described without being necessarily categorized as positive or
negative when psychologists talked about their experience (Table 10).
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Table 10
Frequencies of participants endorsing themes and subthemes related to the care experience in general
Theme Subtheme Frequency #P Sum #P
Beyond Engaging in community work & networking Typical 11
Psychology Working outside the consulting room Typical 11
14
Work includes non-psychological tasks Typical 7
Generically mentioned* Variant 6
New field in Everything still needs to be established Typical 11
Brazil Generically mentioned Typical 9
Not wanting to take away state responsibility Variant 6 14
Projects still searching for best solutions Variant 3
Little Data & literature Variant 2
Personal Mixed up relationship types Variant 6
Closeness Physical proximity in the workplace Variant 5
Generically mentioned Variant 4
11
Touched by stories Variant 4
Being only relation/network for client Variant 4
Links to own migration life Variant 3
Note. *‘Generically mentioned’ is indicated when participants referred to the major theme directly. Sum
# P = Sum of participants referring to the overall theme or its subthemes.
The first main theme concerned psychologists’ feeling that the psychological care of
refugees meant working beyond classical psychological tasks. This theme was a generic variant
subtheme and consisted in three further typical subthemes. As the first subtheme, participants
stressed how important it was to engage in community work, for instance by cooperating with the
institutions, that were relevant to their clients, and to focus on networking between professionals
of diverse disciplines. Psychologists also typically described working outside the usual consulting
sphere and space by leaving their consulting room and accompanying clients to other places. The
last typical subtheme was assuming non-psychological tasks, that transcended their role as
psychologists, such as assisting in solving practical problems, giving advice or engaging in mental
health awareness raising campaigns.
It’s about understanding that mental health is transcended by basic questions. A refugee, who does not have
access to housing, to work, to education, who does not have access to various spheres of life, is going to have
mental health problems. If we, as professionals, aim to ensure basic rights, this will promote the mental
health by some significant steps. There is no point in working only with the suffering of the person if we
don’t provide her with basic conditions to carry on with her life. (P8)
Secondly, participants described how the topics of flight and of mental health support for
refugees have not received much attention and were a new field in Brazil which is only slowly
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emerging now: “I perceive this: it’s all completely new for Brazil. Everything” (P3). A typical subtheme of
this main theme was psychologists pointing to the lack of established structures and projects. As a
variant subtheme, psychologists shared their moral dilemma of wanting to support refugees
through their work in NGOs, but fearing to take away the responsibility of the state. Participants
also reported, as variant subthemes, on the fact, that projects were still developing and searching
for the best solutions to attend to the needs of refugee clients, as well as lack on the lack of scientific
literature and data about refugees in Brazil.
Finally, psychologists experienced a personal closeness to refugees in their psychological
care work.
I always connect myself closely with them. Not like a person that is distant. And we develop very good
bonds. So that, when they meet me in the streets, they see me from afar: “You are here!”, they recognise me,
they remember, they greet me. I feel that they perceive that I really care about them. I think to create bonds
is very important. (P9)
This main theme consisted in six variant subthemes: Participants illustrated, that the client-
professional relationship sometimes got mixed up when clients referred to the psychologist as being
a friend or part of the family (1st). They mentioned the personal closeness generically (2nd) and
explained that it was due to their proximity with clients in the workplace (3rd), and the fact, that
they represented the only network or stable relationship for the client in the new context (4th).
They also felt very touched by clients’ stories of flight and violence (5th): “I was so shocked about her
story, I took her home to have food, to take a shower, to meet my daughter. A little bit crazy no?” (P13).
Furthermore, for some participants, the closeness emerged from links with their own experiences
of migration (6th).
Category B: Negative aspects and barriers

In terms of negative aspects and barriers, five major themes were synthesised. Firstly,
psychologists described the psychological care work with refugees in Brazil as taking place in an
emergency situation: “At first it was a little bit like putting out a fire...” (P8). This main theme
included the typical subtheme that refugee clients’ basic needs remained often unmet. As variant
subthemes, participants perceived that clients’ concerns always appeared very urgent and the care
work as largely improvised: “In the beginning, there were many challenges. I didn’t have a room, a
consulting space, so I saw clients in their private rooms, or on the porch, or in the backyard below
a tree, wherever it was possible.” (P14) A difficulty in planning the psychological care process was
the consequence and categorised as another variant subtheme, as well as participants’ feeling of
working in a chaotic situation.
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Table 11
Frequencies of participants endorsing themes and subthemes related to barriers and negative aspects of the care
experience
Xenophobia Generically mentioned Typical 11

Discrimination Typical 9
14
Racism Variant 3
Mistrust as result of xenophobia Variant 3
Emergency Basic needs are not met Typical 11
Situation Generically mentioned Typical 9
Everything always seems urgent Typical 8
14
Space of care is improvised Variant 5
Planning is difficult Variant 4
Chaotic situation Variant 3
Lack of mental Missing staff Typical 11
healthcare Access problems Typical 9
13
structures Working with low financial resources Variant 6
Missing Missing language skills Typical 11
competencies Missing cultural sensibility Typical 9
13
& experiences Lack of experience leads to paternalism Typical 9
Staff Fatigue Too many cases at same time Typical 12
Helplessness & Frustration Typical 10
12
Anxiousness & Discomfort Variant 6
Burnout Variant 3
Secondly, xenophobia, discrimination, racism and social exclusion were thematised by

psychologists as negatively impacting their clients’ well-being and the psychological care process:
Xenophobia, racism, a high level of exclusion, a precarisation of their lives, makes them feel paralysed and
without possibility to act, without agency […] Looking from a macro perspective, now, in this time that we
live in, there are still so many situations of oppression and so much xenophobia. And they directly impact
the mental health of people. (P5)
Typically, psychologists mentioned xenophobia generically as a negative aspect. A typical

subtheme here was discrimination, including particularly participants descriptions of how they as
professionals experienced disillusionment with their own country when becoming witness of
patients’ suffering caused by social exclusion. As variant subthemes, participants commented on
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issues of racism in particular, and on how refugee clients’ experiences of xenophobia lead these to
mistrust Brazilian institutions and Brazilian people.
Thirdly, the lack of mental healthcare structures in general and specifically for refugees
was categorised as a main theme: “The biggest challenge is working in a third world country. Where you often
have to work without resources.” (P2) As typical subthemes, participants shared, that there was a lack of
staff, and many access problems for clients, such as missing services, long waiting lists, lack of
interpreters, and clients not having the financial means to pay for transport. In terms of access
issues, psychologists also pointed out that psychology is still elitist in Brazil and regarded as only
available to the affluent part of the population who can afford to pay for it privately. As a variant
subtheme, for many psychologists, working with refugees meant working with little or no financial
resources. Therefore, they also had no means for support structures for themselves, such as
supervision. Variant participants mentioned the lack of mental healthcare structured also
generically, in criticising the fact, that mental health support in general received little appreciation
and public financial support in Brazil.
Fourthly, participants negatively remarked on the missing competencies and
experiences of psychologists in the work with refugees. In particular, as a typical subtheme, they
described how they often did not feel competent to work with clients in a language other than
Portuguese: “So working in Spanish, that’s very new. The education in psychology does not mention providing care
in other languages. […] For us it was very challenging.” (P7) Typically, participants also thought that
cultural sensibility was not well developed in professionals. Many mentioned cultural shocks when
confronted with value differences in their clients, especially when these related to questions of
gender roles. Not understanding the “cultural frame of reference” of clients was explained as an
obstacle for building a trusting relationship. Moreover, as another typical subtheme, psychologists
also critically noted that, as a consequence of the lack of experience in dealing with refugee clients,
many Brazilian professionals and institutions tended to patronise refugees and thus to create
relationships of dependency:
I think that refugee housing is not a good alternative for these people in the long run. Because they don’t
have their independence there. They always remain dependent of a space that monitors them and controls
them. What would I want in the long run? That these people can become more independent. (P1)
Finally, and strongly linked to the first, third and fourth theme, psychologists described
issues of fatigue. Namely, they typically referred to being overloaded with cases which rendered
their time and capacities insufficient to listen attentively to clients’ stories or to study how to best
treat refugee clients. Another typical subtheme was the hopelessness and frustration participants
experienced in their work, especially when encountering the structural limitations of the Brazilian
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public system. These limitations included the lack of possibilities to transfer their clients in case of
need for psychotherapeutic, psychiatric or medical attention.
But my biggest difficulty is not having anyone to whom to transfer these people. They open themselves up in
such a difficult situation and I don’t have someone to connect this person to, you know? People are coming
with mental health problems and you are in a position where you don’t have a place to send this person to.
It’s hard and it makes me uncomfortable. You say: “No, there is nothing to be done, I really don’t have
anything.” (P6)
As a variant subtheme, psychologists described anxiety and discomfort as a result of “always

having to say no to clients’ demands” (P5) due to the lack of resources. These feelings also arouse from
constantly listening to refugees’ stories of trauma and violence. As a variant subtheme,
psychologists explicitly mentioned burnout as a potential consequence of these negative aspects. It
was also perceived as resulting from the feeling, that their own work would always remain
insufficient, and from not having hopes for an improvement of the refugee situation in the future.
Sometimes the things touch you a lot. They mess with our own processes, with our mental health. It’s very
common that people get overwhelmed, get burned out… that sort of thing is very common, depression as well.
(P1)
Category C: Positive aspects

Three aspects were thematised positively in the experience of working with refugee clients (Table
12).
Table 12
Frequencies of participants endorsing themes and subthemes related to positive aspects of the care experience.
Theme Subtheme Frequency # P Sum # P
See resilience and Witness determination & resilience Typical 8
transformation See potential for transformation Variant 6
12
See people’s lives change positively Variant 5
Gaining new Cultural learning Typical 10 10
perspectives Exchange about differences Typical 7
Making a difference Generically mentioned Typical 9 9
Firstly, psychologists appreciated seeing their clients’ resilience and transformation.

This main theme related to the typical subtheme of the feeling of personal enrichment, when
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witnessing refugee clients’ determination and resilience. The theme also included the variant
subthemes of recognising clients’ potential for transformation, and actually seeing the positive
changes in the lives of their clients:
What I like is their capacity to find solutions to problems that I myself think of as highly complex. The fact
that when I’m there, listening, without judging, they manage to find answers to their problems on their own,
alone. That capacity is incredible. (P14)
Secondly, psychologists enjoyed gaining new perspectives through their work. This main
theme included the typical subtheme of cultural learning through the encounter in the therapeutic
space and through the study of new languages. It also involved the typical subtheme of feeling
personal growth through the exchange about differences, for instance when listening to refugee
clients’ different points of view: “The whole time they invite us to redefine a bit what our parameters are, those
parameters that we have about what is healthy, what is right, what is normal. Because they bring different views on
certain things.” (P11)
Finally, participants typically pointed out that a positive aspect of their work was the
opportunity to make a difference by being able to advocate for clients, giving voice to
disempowered populations and by establishing relationships with clients:
We should develop the best way to communicate, so that the person can really feel understood, understood in
this wider sense, not just language wise. That is a challenge in the care work. And it’s extremely rewarding.
It’s very beautiful. You can perceive, that yes, arising from that bond that builds itself, the person manages
to achieve her potential, her belonging, her insertion in this culture, she can become the protagonist of her
daily life and resolve the things. (P10)
Category D: Facilitators
Six main themes were synthesised as aspects that facilitated psychologists’ work (Table 13).
Firstly, psychologists referred to the benefit of being flexible and open-minded. This was
commented on generically by variant psychologists, and further specified in four typical subthemes:
Participants underscored the importance of an openness towards clients’ culture of origin (1st). In
fact, the advantage of embracing an openness towards clients’ culture was one of the most
prominent subthemes across all interviews.
It’s about exercising the question of otherness to the maximum. Understanding that this individual was
formed in a very different way than I was. He was formed in a different society with different notions and
parameters than mine. So, I never try to fit the person into my view but yes, to modify my view so to be able
to understand: Where does he depart from, in which way does he view the world? (P8)
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Table 13
Frequencies of participants endorsing themes and subthemes related to facilitators in the care experience.
Flexibility & Openness for client’s culture of origin Typical 13
openness Openness to new & unusual situations Typical 10
Understand & adapt to needs of refugees Typical 9 14
Openness to learn about geopolitical contexts Typical 7
Authenticity & Authentic listening Typical 13
Warmth Warm relationship with refugee is central Typical 11
Generically mentioned Variant 6 14
Self-knowledge Variant 4
Acknowledge suffering Variant 2
Support Interdisciplinary network Typical 9
Structures Good team work Variant 6
13
Cultural mediator Variant 6
Psychotherapy & supervision for professionals Variant 4
Providing a safe Work with groups Typical 13
space and Safe space for being a witness Typical 8
13
working with Work with Families Variant 5
groups Generically mentioned Variant 4
Transparency Generically mentioned Typical 13
& Support clients’ independence Typical 11
13
emancipation Transparency of limits, relationship & role Typical 10
Respect clients’ own solutions & knowledge Typical 9
High Generically mentioned Typical 10
frustration Focus on little things that make a difference Variant 5
10
tolerance Engaging in sports Variant 2
Having institutional support Variant 3
Furthermore, psychologists highlighted the need for an openness towards new, unpredictable and
unusual situations (2nd) and for an understanding and an adaptation of psychological care
approaches to clients’ needs in this context (3rd): “You have to be […] listening in the sense of trying to
understand what is most needed for them at that moment.” (P4). This subtheme included an emphasis of
the importance of a flexible mindset and a softening of theoretical positions, as well as of a non-
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judgemental, not-knowing attitude. An openness and interest in learning about refugees’ contexts
including geopolitical developments was also typically regarded as helpful (5th).
Secondly, participants thematised authenticity and warmth as key facilitators in their
work. They typically referred to an “authentic listening” as a pivotal part of the care work. This
aspect was a very noticeable subtheme throughout the interview data and involved demonstrating
empathy, showing oneself available to clients and listening to what clients had to “get off their chests”.
Most important is empathy. That the other person feels that there is something in you that is not a question
of “I’m here because I’m working.” She needs to feel that there is someone who really cares about what she
is going through. (P10)
Participants also described the centrality of a warm relationship with clients as a typical
subtheme. Furthermore, variant participants stressed that, in order to establish this relationship
and demonstrate authenticity and warmth, a good self-knowledge of professionals was necessary.
Finally, as a variant subtheme, psychologists stated that an acknowledgement of refugee clients’
suffering facilitated the bonding process.
Thirdly, psychologists referred to support structures for professionals as facilitators in
their work. These structures were typically understood in terms of interdisciplinary local networks
of professionals including lawyers, psychiatrists, psychologists and social workers, who would work
together on cases, transfer clients among each other, and enable interdisciplinary learning:
[…] working in a network of professionals, because it is not simply by talking to a psychologist that you
will resolve all mental health problems, no. Sometimes you will need a psychiatrist, a social worker, a
multidisciplinary team, because sometimes the psychic suffering is coupled to the fact that he doesn’t get access
to a document X, that would ensure to bring his child from Venezuela. So, that is why this work in a
network is needed […] I won’t be able to give the appropriate information. So, until what point can I
handle things alone as a professional and from what point onwards will I need a network? (P7)
As a variant subtheme, psychologists emphasised that working in teams was useful to gain
multiple perspectives on cases and to receive personal support in difficult situations. Cultural
mediators were mentioned as useful by variant psychologists, but only two participants had
sporadically access to interpreters. Finally, as a variant subtheme, the same arguments used for the
supportive effect of teamwork were also highlighted in favour of supervision and professionals’
own psychotherapy. However, due to lack of funding, many professionals could not afford their
own psychotherapy, and supervision was rarely in place.
Fourthly, psychologists described providing safe spaces and working with groups as
facilitating their psychological care work. This involved the typical subtheme of working with
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groups, which was, in terms of total codings in the data set, the most notable subtheme, i.e. it was
mentioned most frequently within and across 13 of the interviews:
A very important aspect is working with a more collective perspective. And groups. It’s important that
people can see and recognise each other. The group is very, very important. So that this person can develop
collective actions, group actions in which people can recognise themselves in each other. (P11)
Psychologists explained that group-based approaches functioned well, because the groups
gave refugee clients the opportunity to create networks of mutual support among each other and
to see others in similar situations: “I see that working in groups is great in order to strengthen bonds […] so
that they can exchange and discuss what they see as difficulties they have in common.” (P13) Moreover, groups
represented a solution when there was no time for individual attendance. As a further typical
subtheme, participants highlighted the benefits of clients experiencing a safe space in which the
psychologist and potential other participants could become witnesses of their suffering and assisted
in rebuilding clients’ trust and self-confidence. Variant psychologists also mentioned that it was
useful to attend families instead of working with individuals separately.
Fifthly, participants remarked on the importance of transparency and a focus on
emancipation of their clients. This main theme was typically commented on generically and
consisted of three further typical subthemes. Participants felt it was necessary to support patients’
independence and perceive them agents, in order to help them to structure the next steps in their
lives. Participants strongly recommended not to patronise clients, but rather assist them in finding
their own solutions (1st). A facilitator in this regard was described as adjusting clients’ expectations
through a high degree of transparency of one’s own, professional limits, of the relationship and of
the care process (2nd): “I feel that when you are very honest with them and you explain the procedures […], I
feel that they trust very well and will try to find solutions on the basis of what I said.” (P6) Psychologists stressed
that fostering people’s emancipation also meant displaying respect and sensitivity towards clients’
own solution, and their potentially different types of knowledge of mental health and healing (3rd).
They asserted that, in most cases, clients themselves knew best the solutions to their problems and,
therefore, psychologists called attention to the need for collaboration and knowledge exchange
during psychological care.
Finally, psychologists considered a high frustration tolerance to be a facilitator in their
work. This was typically mentioned by participants generically, and explained by their constant
confrontation with hurdles and structural limits: “You need an immense frustration tolerance. I’m very
perseverant. I think in order to work with people it’s fundamental, it’s crucial, to like people and to have this
resistance. If you don’t have it, it’s going to be hard.” (P2) To maintain such a tolerance and, more generally,
their own mental health, variant participants stressed the importance of focusing on little things
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that made a difference for their clients, and not giving up easily or taking criticism personally. As
further variant subthemes, a particular emphasis was also placed on the need to feel valued by one’s
own institution in order not to become frustrated and on engaging in sports or other personal
activities, in order to maintain one’s resistance and ultimately mental health.
Category E: Necessary changes

Aspects that required changes in order to better the mental health support for refugees in
Brazil and ultimately refugee clients’ mental health were synthesised into three major themes (Table
14).
Firstly, psychologists thematised that the Brazilian state needed to implement more
public structures. This theme included two typical subthemes: The need for policies and
structures for the inclusion and integration of refugees on the one hand, but also for better mental
healthcare in general:
I think the first thing would be that the state fulfils the mental healthcare policies. That all the planning of
mental healthcare, we already have here, finally gets off the paper to exist beyond the paper. […] that the
government places public services right here […] maybe that would allow time for deepening conversations, a
place to listen, so that the person can get rid of his symptom and continue his journey. (P10)
Participants wished to be able to have more time to listen to refugees and to create a sort
of continuity and stability in their work. For this, they thought essential to have more professionals
working in the field and more services and listening spaces available for clients. Regarding the
integration of refugees, psychologists felt that firstly, public policies were needed to organise the
arrival and transition of refugees in Brazil and secondly, and more importantly, the implementation
of these policies was required, i.e. guaranteeing basic living conditions for refugees, recognising
work diplomas and assisting in integration processes.
[We need] a policy that also aims to integrate refugees, facilitating their access to the labour market.
Recognition of diplomas and also something that lets immigrants and refugees have equal opportunities to
work, guarantees labour rights. Because many times the immigrant is also exploited for not knowing how
worker protection laws function. It would be interesting to create a solid national policy that is sensitive to
the particularities of different ethnic groups. (P8)
Secondly, participants repeatedly stressed the need for anti-discrimination work and a
conscientization of the population regarding the topics of culture and flight. This was mentioned
generically and in two typical subthemes: First, participants explicitly wished for more cultural
awareness and multi-language competencies in staff of public institutions. In doing so, they
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highlighted, that cultural studies should be included as a part of the university education of
psychologists. As the second typical subtheme, psychologists stressed the need for campaigns
against racism and anti-discrimination and expressed how such efforts and processes could shift
the public mindset towards an appreciation of difference.
Table 14
Frequencies of participants endorsing themes and subthemes related to necessary changes to improve the psychological care
with refugee clients
Theme Subtheme Frequency #P Sum # P
State needs to Provide policies & structures for inclusion & Typical 10
provide structures integration of refugees
14
Increase public mental healthcare structures Typical 10
Conscientization Generically mentioned* Typical 13 13
& Anti- Raising cultural awareness in staff Typical 10
Discrimination Campaigns against racism & discrimination Typical 9
Need for a more Education of psychologists needs to be less Typical 10
social perspective individualised and focus on creating networks
in mental More social & community work is needed Typical 7 13
healthcare Psychologists need to see individuals in context Variant 6
Brazil still is a very racist, xenophobic country despite the propaganda saying the opposite: “Country of all”
and all that, but we know, that actually it isn’t like that. We are still living that old discourse that is very
present in the society that “the immigrants come here, they will steal our jobs, they will overburden our
services.” In short, in some way they will represent in our society that what, in reality, already didn’t work.
This is based on a very wrong perception of reality, an almost delusional perception because in fact, […],
Brazil has more emigrants outside of Brazil, than immigrants inside. It’s a very wrong perception. I think
we need to educate the own population. (P3)
Finally, psychologists felt that a more social perspective was needed in Brazilian mental
healthcare. This was generically claimed by variant psychologists, but it was also explicated in three
subthemes: First, participants typically depicted a required shift in the education of psychologists
from individualised approaches to a concentration on the creation of better interdisciplinary
networks in the mental healthcare sector: “I think that psychology could work with that: to create bridges, to
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create support networks in one's own locality. Beyond the office, beyond psychotherapy, thinking about the
communities.” (P9) Second, participants typically saw a greater focus on working with communities,
families and groups as necessary. Under this subtheme, they also outlined the need for a higher
valorisation of social work, allowing for preventative approaches, instead of a medicalisation of
suffering:
We have to get out of our spaces, we should not just stay in our four individual walls. […] I think that the
space [...] needs to be a space for the promotion of mental health. And how to promote mental health? By
valuing social initiatives and working with the development of relationships, of art and culture. (P11)
Finally, as a variant subtheme, psychologists spook about the need for professionals to see
refugee clients in their particular socio-political context.
Comparing across regions and approaches

The participants in this study worked in very diverse regions of Brazil. In the analysis of
the data, we looked for diverging perspectives related to place of work. However, no prominent
differences in the perspectives could be found except for the tendency of participants in the South
to stress the lack of data on refugee mental health in Brazil and describe the dilemma of taking
over a responsibility that could be considered a state responsibility through their work. Similarly,
we could not find differences in participants’ experiences when comparing across theoretical
approaches to psychological care work.
Discussion
The present study is, to our knowledge, the first to investigate how psychologists experience
working with refugees across various regions of Brazil. It provides insights into what these
psychologists perceive as positive aspects and facilitators or negative aspects and barriers in their
work. Furthermore, it sheds light on what psychologists see as necessary changes in order to
improve the mental health support of refugees in Brazil and ultimately refugee clients’ mental
health. The analysis of the results yielded a total of twenty themes, some of which concern
psychologists’ characteristics, such as a flexible and transparent attitude. Others relate to specific
useful approaches, for instance engaging in community work or working with groups. Many of the
themes describe structural issues, such as the lack of mental healthcare structures or high levels of
xenophobia in the country. As such, the present study confirms many of the previous international
findings in the area of mental healthcare for refugees (e.g. Duden et al., 2020; Karageorge et al.,
2017). It also adds new insights, such as highlighting psychologists’ perception of working in a
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precarious context with refugees in Brazil and in an emergency-like situation, where clients’ needs
seem always urgent and solutions appear as mainly improvised. Three main aspects of the findings
will be discussed here with regard to the scientific literature.
Working in a novel field and precarious context

Even though Brazil has a long history of migration (Patarra & Fernandes, 2011) and has
increasingly become a host country for refugees (CONARE, 2019; Jubilut, 2006), working with
refugees seems to be a novel field for psychologists. Psychologists report a lack of experience and
competencies and missing Brazilian scientific literature to base their approaches upon. This
perception relates to the fact that the topics of culture and refugee have not received much
attention publicly in Brazil or Latin America in general and even less so in Brazilian psychology
education curricula (Knobloch, 2015; Parra, 2013). Internationally, the need for including these
topics into the training of psychologists have been stressed by others (Christopher et al., 2014), as
professionals often feel ill-equipped to deal with refugees’ specific needs (Guhan & Liebling-
Kalifani, 2011) and with cultural or language differences (Sandhu et al., 2013). The omnipresent
contextual instability faced by many refugees (Duden et al., 2020; Maier & Straub, 2011) and their
frequent experiences of trauma (Barrington & Shakespeare-Finch, 2013) confront professionals
with unique challenges (Duden et al., 2020; Karageorge et al., 2017). In Brazil, the precarious
context of both clients and professionals come into play as additional factors. For instance, in the
present study only one of the participants worked for an institution that was financed by the state.
Most of the interviewed psychologists worked for non-governmental organisations or even
attended refugee clients on a completely voluntary basis. This is but one example of a context
which is characterised by a lack of mental healthcare structures in general, missing services for
refugees more specifically as well as lack of support for psycho-social professionals. Moreover,
many refugees in Brazil struggle with unmet basic needs and policies for their integration are largely
absent (Knobloch, 2015; Moreira & Baeninger, 2010).
Impacts of the work on psychologists and the need for adequate support and
training
Professionals working with refugees worldwide often report high levels of stress and
vicarious traumatisation (Barrington & Shakespeare-Finch, 2013). In the present study
psychologists described experiencing helplessness and frustration, fatigue and burnout. However,
and similarly to Barrington & Shakespeare-Finch (2014), participants also reported benefits of their
work, such as experiencing personal growth, gaining new perspectives and feeling inspired by
witnessing strength in many of their clients. Such positive impacts have been conceptualised as
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vicarious post-traumatic growth (Barrington & Shakespeare-Finch, 2013). Like other studies
(Apostolidou, 2016a, 2016b; Duden et al., 2020; Barrington & Shakespeare-Finch, 2013, 2014), the
present study highlights the importance of support structures for professionals, which include
receiving supervision, psychotherapy and working in interdisciplinary networks. Such structures
might prevent burnout and turnover, since, by receiving support themselves, psychologists might
feel valued in their work and develop stronger frustration tolerance. Consequently, they might be
better able to assist clients’ emancipation, communicate safety and transparency and establish an
authentic and warm relationship with their clients. The missing competencies reported by
participants in the present study may, furthermore, be counteracted by continuous education and
training. This need for training of psychologists with respect to the work with refugees has also
been stressed by others, particularly regarding cultural awareness or cultural humility (Christopher
et al., 2014; Knobloch, 2015; Watters, 2001). The present study points additionally to the fact, that
a training of psychologists which prepares them for attending refugee clients, might help them to
better cope with the emotional and strucutral challenges of their work. A particular one of these
challenges is addressed in the following paragraph.
Discrimination of clients and disillusionment of psychologists

Many participants in the present study connected the impacts of their work on themselves,
particularly the frustration they felt, to their clients’ experiences of xenophobia and racism. When
asked about what needed to change to better the mental health support for refugees, many
participants underscored the urgency to raise awareness among the Brazilian population about the
topic of flight with the aim to decrease discrimination. Discrimination has shown to be one of the
major challenges for the integration of refugees in Brazil (Barros & Martins-Borges, 2018; Moreira
& Baeninger, 2010) and a body of research has found that facing discrimination and racism
negatively impacts one’s mental health (Ellis et al., 2008; Malott & Schaefle, 2015). Moreover, in
our study, professionals seemed to suffer indirectly from the xenophobia to which their clients
were exposed, for instance by experiencing disillusionment with their own country. Previous
studies have found that psychologists often go through processes of shame (Parker & Schwartz,
2002) and become more aware of their “Whiteness” (Wihak & Merali, 2007) when working and
training in multicultural settings. Professionals’ frustration with their own country may be one of
the reasons why many felt motivated to engage in aspects beyond classical psychological tasks,
since this might help professionals to relief feelings of helplessness. However, the unique psycho-
social needs of refugee clients might also render approaches “beyond-psychology” necessary or
even mandatory (Watters, 2001), as discussed in the following paragraph.
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Flexibility, adaptation and a contextual perspective

Our findings point to the usefulness of a social and contextual perspective when working
psychologically with refugees (Duden et al., 2020; Drožđek, 2007; Murray et al., 2010). Participants
particularly highlighted the benefit of working in groups (Fischman & Ross, 1990), as well as of
taking the geopolitical situation and context of the client into consideration, instead of focusing
only on individual psychological problems. Taking clients’ context in mental healthcare settings
into account has previously been labelled “structural competency” and described as important, when it
comes to dealing with clients’ experiences of inequality (Metzl & Hansen, 2014). The participants
of the present study felt that a contextual perspective called for an openness to adapt one’s
approach to the specific needs of each refugee client. The constant adaptation of one’s work to
clients, such as proposed by integrative psychotherapy, a softening of theoretical positions, and an
acknowledgement of what is most needed for each client in her specific situation has been outlined
as beneficial in mental healthcare in general (Fisher & Boswell, 2016; Norcross & Wampold, 2018,
Wampold & Imel, 2015) and especially with refugee clients (Duden et al., 2020; Karageorge et al.,
2017).
Other studies have already noted, that psychological care for refugees demands high
flexibility of professionals and often exceeds classical psychological work (Duden et al., 2020;
Bäärnhielm et al., 2017; Drožđek, 2007; Savic et al., 2016; Watters, 2001). Some authors have
stressed the advantages of exceeding classical psychological work, for instance by taking on a
political stance in mental healthcare and advocating on behalf of clients (Karageorge et al., 2017;
Puvimanasinghe et al., 2015; Rousseau, 2018). Such a political stance may, firstly, help clients
directly with practical matters and better their living situation in the post-migration context.
Secondly, it may also indirectly help by building trust in refugee clients towards their psychologist
and facilitating bonding (Karageorge et al., 2017; Puvimanasinghe et al., 2015; Watters, 2001).
Advocating on behalf of refugee patients may be seen as necessary socio-political engagement of
psychologists and as an expansion of the psychologist’s professional role (Drožđek, 2007). For
some authors, it evens forms part of the ethical duties of psychologists (Zion, 2013).
However, an extension and adaptation of the psychologist’s role might entail the danger of
professionals overburdening themselves, while attempting to solve every single problem of their
clients. It may thus cause an overinvolvement of professionals, counteract patients’ independence
and self-efficacy and create a relationship of dependency with clients (Codrington et al., 2011;
Kronsteiner, 2017). The flexibility may, consequentially, lead to an even further marginalisation of
clients (Jordan & Seponski, 2018), and can also increase the likelihood of burnout in professionals.
Moreover, the need to exceed professional boundaries and go “beyond psychology” might be linked to
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psychologists’ personal wish to “make a difference” and could risk deviating from clients’ individual
psychological problems, hence compromising the therapeutic process (Apostolidou, 2015).
On the other hand, psychological work, that does not involve such flexibility and
adaptability to clients’ needs and context, might imply a too biomedical and rigid perspective on
mental health and risk to ignore the multidimensionality and complexity of mental health problems
which are inserted in a socio-political context (Marsillac et al., 2018; Yamamoto, 2007). Particularly
with respect to the therapeutic relationship, a flexibility in psychologists’ approaches to their work,
role and boundaries are a debated issue in the scientific literature (Speight, 2012; Zur, 2004).
Boundary crossings in the relationship, for instance, have been called a “slippery slope” and perceived
as ethically difficult, due to the potential of exploitation of clients (Speight, 2012, p. 134).
Meanwhile, a flexibility in boundaries with refugee clients can also be seen as strengthening bonds
and might be especially important for culturally competent practise (Speight, 2012; Zur, 2004).
Considering the noticeable link of refugee patients’ psychological suffering with socio-
political factors (Drožđek, 2007; Watters, 2001), it might not be surprising that an increased
politicisation of professional identity and practise have been reported among practitioners who
work with refugees and asylum-seekers (Apostolidou, 2015, 2016a). Independently of the stance
one takes regarding the exceedance of classical psychological work, it certainly seems to constitute
a balancing act for professionals. Therefore, psychologists need to be aware of their positionality
and the potential risks associated with it and reflect upon their professional roles and their
boundaries, for instance in supervision. Again, this reinforces the necessity of support structures
for professionals (Apostolidou, 2016b).
Limitations of the study

The present findings are limited to the extent that, firstly, we only obtained professionals’
perspectives. Future research should take into consideration the experiences of refugee clients, as
this might lead to different insights into the psychological care process. Also, refugees form a very
heterogenous group and might have quite diverse experiences and perspectives. In the present
study, psychologists mostly worked with clients from Venezuela, Haiti, Syria and Colombia, but
the interviews were not focused on differences between psychologists’ experiences in relation to
the countries of origins of their patients. Taking the background of clients into account, such as
their country of origin, gender and their individual flight history might provide valuable information
for adapting and improving the care process.
Secondly, the participants in this study worked in various, culturally and economically
diverse, regions of Brazil and places of work. Even though we could not find diverging perspectives
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related to regions or place of work, further studies may benefit from investigating and comparing
the variation in psychologists’ perspectives by work region in more detail.
Thirdly, the findings are based on our own interpretations and, even though we
consistently reflected upon our positionalities, other researchers may have developed different
themes and have reached different conclusions when analysing the same data. We did not send
drafts of our results to the participants, which would have increased the likelihood that our
interpretations represent their experiences. Meanwhile, we had sent the interview transcripts to
participants for member checking (Hill, 2012), but had not received revisions.
Fourthly, the primary researcher of this study is German, which might have limited the
extent to which participants in Brazil felt comfortable to articulate their own point of view.
However, care was taken to establish rapport with participants through prior informal
conversations and the interview questions were formulated very openly. In addition, all of the other
research team members were Brazilian psychologists.
As a final limitation, results of this study included frequency counts for themes, a debated
issue in qualitative research. Frequency does not necessarily represent the significance of a theme
as there is a large variety of reasons why participants might not have stressed a theme (Braun &
Clarke, 2019).
Conclusion and Implications

To our knowledge, this study is the first to investigate the perspectives of psychologists
who work with refugee patients in the Brazilian context. As the study itself shows, the topic of
mental health support of refugees has received little attention in Brazil, particularly in the education
of psychologists. The study highlights the importance of an awareness, that psychologists do not
work independently of the geopolitical, social and economic context and conditions in which they
and their clients are located. For the Brazilian context, this implicates that, in order to tackle
refugees’ mental health issues, policy makers, educators and programmes need to address
discrimination in the society, the lack of integration policies and unmet basic needs of refugees, as
well as the missing implementation of mental healthcare structures more generally. Future research
could take this study on the perspectives of psychologists in Brazil into consideration in order to
foster a more collectivity-focused and contextual understanding of mental health and therapeutic
processes. This suggestion would be in line with what has been stressed by psycho-social, systemic
and community psychological perspectives.
To assist psychologists in dealing with the burdens and responsibilities they encounter in
their work, support structures, such as supervision and interdisciplinary networks need to be
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created urgently and the topics of flight and culture have to receive more attention in the Brazilian
scientific realm, as well as in the education of psychologists. The latter could improve the mental
health support for refugee clients by fostering a contextualised perspective of clients and their
mental health and by training professionals to assume an attitude of transparency, authenticity,
warmth, flexibility and openness. This may implicate integrating geopolitical and cultural subjects
into education curricula, assisting professionals to continuously seek to expand their knowledge,
foster their self-reflection and the exchange with professionals from different disciplines on a
regular basis.
For professionals who provide psychological care for refugees, the present study provides
useful insights for their work, such as that, unavoidably, they will encounter structural limitations
and sometimes they might have to move beyond their classical psychological work, in order to best
support their clients. Also, professionals can conclude from the present study that there seems to
be a tendency for psychologists to become very close to refugee clients and sometimes mix-up
professional with private relationships. However, there also appears to exist a variety of aspects
that facilitate the coping with these challenges for psychologists, such as transparency of one’s own
limits, good team work, support structures, group-based approaches, as well as focusing on little
things that make a difference for clients.
Providing competent mental healthcare services for refugees clearly requires significant
financial resources (Murray et al., 2010). Meanwhile, current tendencies in Brazil rather indicate
cut-backs in public healthcare spending, including mental health (Doniec et al, 2018). This very
likely will have detrimental effects for the most vulnerable parts of the population, including
refugees.
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Chapter 7
Psychotherapy with Refugees – Supportive
and Hindering Elements
Published as
Duden, G.S. & Martins-Borges, L (2020). Psychotherapy with Refugees – Supportive and
Hindering Elements. Psychotherapy Research. Doi: 10.1080/10503307.2020.1820596
Section II | Chapter 7 Psychotherapy with Refugees
Abstract
Globally, nearly 80 million people are forcibly displaced. Being a refugee can impact one’s mental
health profoundly. Although specific approaches for psychotherapy with refugees have been
developed, this study is the first to investigate psychotherapy with refugees in Brazil. Semi-
structured interviews were conducted with 18 psychotherapists in Brazil and analysed using
consensual qualitative research and thematic analysis. Supportive and hindering elements in
psychotherapy with refugee patients in Brazil were identified at eight different levels: the patient,
the therapist, their relationship, the setting, the psychotherapeutic approach, the context of the
patient, the context of the therapist and the societal context in Brazil. Hindering elements in the
therapy include missing preparation for the integration of refugees, lack of interpreters, patients’
mistrust and therapists feeling untrained, helpless and becoming overinvolved. Supportive
elements include a trusting therapeutic relationship, therapists’ cultural humility and structural
competence, patients’ societal inclusion as well as working with groups and networks. This study
shows that in light of the enormous structural challenges for the mental well-being of refugee
patients, therapists’ flexibility and the reliance on collective work and networks of support is crucial.
Future research might investigate in more detail notions of collectivity-based mental healthcare in
intercultural therapy settings.
Keywords: Transcultural Psychotherapy; Refugees' Mental Health; Brazilian Health Care;

Migration; Providers' Perspectives; Qualitative Research
Clinical or methodological significance of this article: This is the first study of its kind
investigating psychotherapy with refugees in various Brazilian states and providing insights into
what psychotherapists experience as supportive and hindering in their work. The results highlight
the importance of adaptability and structural competence of psychotherapists, a move from
knowledge-based cultural-competence concepts towards more flexible notions such as cultural
humility and the usefulness of collectivity-based work strategies such as networks, co-therapy,
teamwork and group therapy. Furthermore, collectivity-based strategies could help to counteract
the feelings of helplessness in therapists, which, as this study suggests, might stem from contextual
struggles, such as lack of funding and unmet basic needs of patients, and which are, in the case of
Brazil, reinforced by the precariousness of the ongoing social, economic and political insecurity.
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Introduction
Historically, psychology has relied on theories and data derived from a specific and small
part of the world’s population, namely Euro-North-Americans (Hartmann et al., 2013; Parra, 2013;
Wampold & Imel, 2015). However, culture influences constructions of pathology, as well as forms
of healing (Kirmayer, 2004). Investigations of the concepts of diagnosis, psychotherapeutic
treatment approaches and settings in a greater variety of cultures and countries are needed (Duden
et al., 2020; Parra, 2013). The present study focuses on psychotherapy in Brazil and specifically on
the treatment of refugee patients.
Since its re-democratisation, Brazil has become a country of resettlement with specific laws
for refugees (Jubilut, 2006). However, little is known internationally about refugees in Brazil and
especially about their mental healthcare (Teixeira et al., 2013). The national Brazilian healthcare
system (SUS), established in 1988, aims to provide comprehensive, universal healthcare free of
charge (Loch et al., 2016; Paim et al, 2011). It is based on an ample understanding of health,
incorporating physical, socioeconomic and cultural factors. Brazilian law states the right of access
to the SUS for everyone, without any discrimination (Böing et al., 2009), thus including refugees.
Brazilian mental health policy, being strongly influenced by the democratic psychiatry movement
in Italy (Goulart & González Rey, 2016), emphasises a model of family- and community-care
(Marsillac et al., 2018). Psychosocial care centres (CAPS), inaugurated as alternatives to traditional
asylums, form the cornerstone of Brazilian mental healthcare (Goulart & González Rey, 2016).
These centres entail multi-professional teams which support people with mental health problems
by allocating resources within the community, such as through home visits and community
activities, as well as by offering therapeutic care adapted to each patient (e.g. family and group
therapy, individual psychotherapy, work-related workshops). All of these services are offered free
of charge and can be one-time or of long-term duration (Goulart & González Rey, 2016).
The creation of the SUS has certainly improved the access to (mental) healthcare in Brazil.
However, problems remain: units are fragmented, poorly interlinked and overly bureaucratic
(Böing et al., 2009), coverage is distributed unequally due to limited governmental spending on
mental healthcare (Doniec et al., 2018; Marsillac et al., 2018) and there is a lack of specialised
services for refugees (Bógus & Rodrigues, 2011). The demand for the latter, as well as more
information on the needs of refugees in Brazil has increased dramatically, in particular with the
humanitarian crises in Venezuela from 2016 onwards (CONARE, 2019). The few mental
healthcare services which are specialised in treating refugees are usually offered by volunteers, by
non-governmental organisations (NGOs), or as part of “community-outreach”-projects of
universities (Jubilut, 2020).
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Refugees form a very heterogenous group; however, they are often placed into a single
category due to the commonality of their predicament. Certainly, not all refugees develop mental
health problems, but higher rates of mental disorders and psychological symptoms compared to
the general populations in host countries seem common following the experiences of violence,
war, displacement and difficulties in resettlement (Carswell et al., 2011; Fazel et al., 2005). Reports
have shown elevated rates of anxiety and depression, as well as a high prevalence of post-traumatic
stress disorder (PTSD) – sometimes registered to be up to 10 times higher than in the general
population (Fazel et al., 2005; Lindert et al., 2009). In the Brazilian context, a study of Haitian
immigrants in Southern Brazil yielded a PTSD prevalence rate of 9.1% and found that depression
and anxiety symptoms were in the clinical range in 10.6% and 13.6% of participants respectively
(Brunnet et al., 2018). However, this study remains one of the very few investigations on immigrant
and refugee mental health in Brazil, and a lack of research and data in this area persists (Moraes
Weintraub, 2012; Teixeira et al., 2013).
Internationally, studies investigating diverse facets of psychotherapy with refugees have
increased (Duden et al., 2020; Barrington & Shakespeare-Finch, 2013). For instance, Björn et al.
(2013) used content analysis of videotaped therapy sessions with refugee families to determine that
professionals who possessed an awareness of the sort of lives refugees had lived before their flight
to a new country were able to better accommodate patients’ needs. Other studies found that
establishing a trusting relationship with refugees is a priority and challenge in the therapy and might
take a long time, as negative past experiences, unfamiliarity with the host country’s healthcare
system, negative preconceptions of psychotherapy, and hostile attitudes of receiving communities
seem to be major barriers for the development of trust (Codrington et al., 2011; Sandhu et al.,
2013). Furthermore, the therapeutic relationship is influenced by the presence of interpreters who
are often considered indispensable when working with refugee patients (Codrington et al., 2011;
Mirdal et al., 2012; Puvimanasinghe et al., 2015). Miller et al. (2005) observed, for example, that
interpreters had an impact on the therapeutic alliance as well as on complex emotional reactions
within the therapy triad, which are exemplified by therapists feeling excluded from the bond
forming between interpreters and patients.
Further investigations on psychotherapy with refugees have focused on aspects such as
trauma therapy. Some have found that the witnessing and validating of traumatic experiences by
an outsider can play an important role in a healing process (Griffiths, 2001). This idea forms the
base of the testimony therapy approach with refugees (Lustig et al., 2004). The necessity of refugees
“talking through” their traumatic memories, however, remains a debated issue (Shearing et al.
2011). For instance, Savic et al. (2016) found that among Sudanese refugees in Australia many
preferred “getting on with life” rather than talking about psychological problems. Vincent et al.
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(2013) observed ambivalences about engaging in trauma-focused cognitive-behaviour therapy

among asylum-seeker patients, especially when the asylum-seekers were living in fear of
repatriation.
Additionally, two current metasyntheses of qualitative studies investigating psychotherapy
with refugee patients (Duden et al., 2020; Karageorge et al., 2017) underscored the importance of
two major aspects: Firstly, they emphasised the huge impact this type of work can have on
professionals. Factors such as patients’ ongoing contextual instability influence professionals
emotionally and can lead to changes in professional identity, as has also been reported by other
studies (e.g. Apostolidou, 2015; Barrington & Shakespeare-Finch, 2013; Puvimanasinghe et al.,
2015). Secondly, the metasyntheses highlighted the benefit of adapting therapeutic methods to
patients. This finding is supported by literature concerned with refugee patients, but also with
patients from the general population (Savic et al., 2016; Wampold & Imel, 2015). Adapting methods
and addressing refugees’ complex needs through advocacy, psycho-social as well as interdisciplinary
work has shown especially helpful in the eyes of patients and staff (Codrington et al., 2011; Watters,
2001). For instance, Al-Roubaiy et al. (2017) reported that there was a strong whish among Iraqi
refugees in Sweden that therapists recognise and address their exile-related stressors, which they
perceived as the foremost reason for seeking psychotherapy. The two metasyntheses also observed
professionals’ cultural humility (Kirmayer, 2012b; Tervalon & Murray-Garcia, 1998), as well as their
structural competence, i.e. an awareness of the socio-political context of patients (Metzl & Hansen,
2014) to be central to a positive experience of mental health support.
Certainly, the literature about psychotherapy with refugees is growing; however, most of
the studies cited originate from Western Europe, North-America and Australia. The present study
aimed to focus on the experience of psychotherapists who work with refugee patients in the
Brazilian context. We suggest that solutions to difficulties encountered by these psychotherapists
could be a valuable resource for psychotherapy with refugees in other countries (Parra, 2013). In
other words, such an investigation may advance our international knowledge base of transcultural
psychotherapeutic treatment for refugee patients and facilitate structural and clinical support for
this group. As the experiences of psychotherapists working with refugees in Brazil may be very
complex and have yet to be investigated, we apply qualitative methods for the understanding of
these perspectives. Specifically, we pose the question of what psychologists who conduct
psychotherapy with refugees in Brazil perceive as supportive and as hindering elements in their
work.
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Method
Study design, participants and procedures

This research rests on a constructivist ontology, a subjectivist epistemology and uses
qualitative procedures of inquiry. The current article is part of a larger study investigating the mental
healthcare of refugees in Brazil. This study specifically is concerned with the experience of
psychotherapists working with refugees in Brazil. Participants were recruited using gatekeepers and
by contacting local NGOs and subsequently via snowball sampling.
Individuals were only eligible to take part in the study if they held a university degree in
psychology. Undergraduate degree programs in Brazil conform to a national curriculum and
involve three years of general studies in psychological science, followed by two years of area-
specific and practical internships (Rezende, 2014). Advanced academic degrees were not an
inclusion criterium, but six of the participants held masters’ degrees and four also had a doctoral
degree. For more details on psychology curricula in Brazil please see for instance Rezende (2014).
Another inclusion criterium was the requirement that participants had been working
psychotherapeutically with refugee patients for at least six months. There is no formal license to
practise psychotherapy in Brazil, and psychologists can work psychotherapeutically after finishing
their university degree. Therefore, participants were asked to self-define their work, and only
participants who declared their work to be clinical and psychotherapeutic were included.
Furthermore, all participants of the present study were registered with a Regional Council of
Psychologists, which forms part of the Brazilian Federal Council of Psychology and serves as an
ethics board of the psychology profession.
All participants had been educated in psychoanalytic theory during their university studies
except one, who had focused on systemic therapy. Seven participants had additionally taken part
in intercultural psychology university courses and subsequentially specialised in ethnopsychiatry
(Devereux, 1978; Martins-Borges & Pocreau, 2009a) during their practical internships. None of the
participants worked in the public healthcare system with their refugee patients. Instead, 14
participants treated refugee patients on a volunteer basis and did not receive any form of payment
for this work. Three participants were linked to a university which financed their work through a
community-outreach program (Jubilut, 2020). One participant was financed through an
international NGO. Participants worked with refugee patients in their private practices, in spaces
provided by universities, a hospital or NGOs. As many participants did not keep systematic records
on their patients, no average of therapy duration nor number of patients per therapist can be
provided here. However, in their interviews, participants reported seeing their patients over
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durations varying from three sessions only to periods of over two years depending on patients’
needs, but also on the time and financial capacities of therapists.
All participants gave their informed consent. Ethical approval was obtained from the Ethics
committee of the University of Osnabrück. A total of 18 psychotherapists were interviewed (Table
15) using a semi-structured interview guideline, which had been pilot tested to ensure the
unambiguity of questions. The semi-structured interviews lasted between 40 minutes to 2 hours
and were conducted in Portuguese, face-to-face at workplaces of participants (n=12) or via skype
(n=6). Each interview was audio recorded and transcribed. Identifying information was removed
and the names of the participants were substituted for numbers.
Data analysis
In line with the subjectivist epistemology of the present study, transcripts were analysed
adopting principles of consensual qualitative research (Hill et al., 2005; Williams & Morrow, 2009)
and thematic analysis (Braun et al., 2014) focusing on the explicit meaning in the data. In total,
three researchers were involved in the analysis process, a German clinical psychologist and two
Brazilian clinical psychologists. Firstly, every interview was read thoroughly and given a title with
its most prominent message. Additionally, word clouds were generated to create an overview of
noticeable themes in the data. Subsequently, a data-based analysis style was used, whereby the first
author identified units (codes) in the transcripts and collated them into categories of meaning
(themes and subthemes), thus developing a coding tree. This procedure was undertaken in
Portuguese. The coding tree was re-applied to the data by the first author and by the two other
researchers independently. Researchers evaluated the fit of the coding tree, translated it into
English and discussed the codes, subthemes, themes and translation until a consensus about their
structure and labels was reached. Subsequently, the qualitative analysis software MAXQDA
(VERBI-Software, 2007) was used to organise the text of all interviews into the themes and obtain
the frequencies of participants who talked about each theme (Table 16). This quantification does
not allow for inferences of statically valid prevalence. It was used merely to gain an overview of the
representation of each theme in the data set, labelling themes with “general” if they applied to 17-
18 cases, “typical” if endorsed by 11-16 participants, “variant” for less than 11 but at least three
cases, and “rare” for one or two cases (Hill et al., 2005).
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Table 15
Characteristics of participating psychotherapists
Characteristic (n=18) M (SD)/n range/%
Age, years 35.16 (11.6) 23-60
Gender
Male 3 16.7
Female 15 83.3
Experience as
a therapist, years 10.3 (10) 1-30
a therapist with refugees, years 4.4 (2.8) 1-9
City (State) of work
Boa Vista (RR) 1 5.6
São Paulo (SP) 5 27.8
Curitiba (PR) 5 27.8
Foz do Iguaçu (PR) 1 5.6
Florianópolis (SC) 6 33.3
Country of origin
Argentina 1 5.6
Brazil 13 72.2
Colombia 1 5.6
Lebanon 1 5.6
Syria 1 5.6
Uruguay 1 5.6
Working with interpreters
Sporadically 2 11.1
Never 16 88.9
Languages of therapy
Portuguese 18 100
Spanish 10 55.6
French 5 27.8
English 4 22.2
Arabic 2 11.1
Psychotherapeutic approach
Psychoanalysis 10 55.6
Ethnopsychiatry 7 38.9
Systemic psychotherapy 1 5.6
Work financed by
University 3 16.7
International NGO 1 5.6
Voluntary 14 77.8
Note. Data are mean (standard deviation) or n and range or percentages. Percentages are rounded
to one decimal place.
Author positionality
The first author is a doctoral candidate in psychology and served as the study’s principal
investigator and first coder. While she grew up in a city in eastern Germany, her experiences and
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academic interests in migration have raised her awareness for structural challenges in post-
migration settings and the need for culturally sensitive service providers. She lived in Brazil for
several years, worked in psychotherapeutic clinics for refugees in Germany and Brazil and
participated in research activities in a Brazilian university. These experiences, as well as the fact that
the co-author and the additional coder are Brazilian clinical psychologists, increase the likelihood
that local significations and the way therapists in Brazil speak about their work were captured
adequately. All three researchers have experience in qualitative research methods, including
interview studies and qualitative analysis, as well as in the use of analysis software. The authors
expected psychotherapists to highlight the Brazilian political situation as a main challenge in their
work.
Results
The analysis showed that therapists’ accounts of their work experiences involves eight levels
of description. Figure 16 depicts these levels in an interconnected way:
Figure 16
The eight levels of analysis
The general Brazilian context (BC) provides the all-encompassing background for the therapeutic
encounter. Within this general Brazilian context, the therapist and patient have further contexts
which are more specific to them (e.g. their family etc., here represented as TC and PC) and which
partly overlap. One element of the context is the specific setting (S) in which therapist and patient
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meet and in which the therapy takes place, as well as the specific therapeutic approach (A). When
therapist (T) and patient (P), each with their unique characteristics, encounter each other in the
therapeutic space, they start forming a therapeutic relationship (R), depicted in the centre of the
figure. For each level, themes (see Table 16) were formulated. In the following section, each of the
levels with its themes will be described in more detail.
Table 16
Level of analysis, themes and frequency of occurrence of each theme
Level Supportive/ Theme Frequency of
Hindering Occurrence (#T)
Brazilian Hindering Inadequate preparation to receive & integrate General (17)
Context refugees
Access to mental healthcare is difficult Typical (16)
Mental healthcare system lacks funding & Typical (13)
communication between services
Patients’ Hindering Basic needs not met Typical (13)
Context Facing prejudice, discrimination, racism Typical (14)
Bureaucratic barriers to integration Variant (10)
Instability Variant (10)
Family separation & isolation Variant (8)
Injustice & no reparation Variant (8)
Supportive Inclusion & access Typical (14)
Social contact Variant (9)
Basic needs satisfied Variant (6)
Therapists’ Hindering Voluntary work Variant (6)
Context Feeling untrained Variant (5)
Working alone & being isolated Variant (5)
Conflicts in teamwork Variant (3)
High number of cases Rare (2)
Supportive Interdisciplinary network Typical (15)
Supervision Typical (15)
Therapists’ own psychotherapy Typical (14)
Therapists’ strategies to cope Typical (13)
Teamwork Typical (12)
Education in cultural psychology Variant (9)
Patient Hindering Mistrust Variant (8)
Unfamiliarity with psychotherapy Variant (8)
Talking about suffering is hard Rare (2)
Supportive Desire to talk & engage Variant (5)
Strength & resilience Variant (4)
Therapist Hindering Getting overwhelmed Typical (15)
Ethnocentrism Variant (9)
Feelings of power & helplessness Variant (6)
Supportive Cultural decentring & humility General (17)
Contextual & political awareness General (17)
Theoretical decentring Typical (13)
Desire to attend & genuine interest Typical (13)
Self-awareness Variant (8)
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Table 16
Level of analysis, themes and frequency of occurrence of each theme
Level Supportive/ Theme Frequency of
Hindering Occurrence (#T)
Therapeutic Hindering Bonding takes longer Variant (8)
Relationship Overidentification with patient Variant (5)
Supportive Relationship as most important aspect Typical (12)
Speaking patient’s language Typical (12)
Trust Typical (11)
Being there Typical (11)
Having had similar experiences Variant (7)
Show interest in culture Variant (6)
Setting boundaries Variant (3)
Flexible understanding of the relationship Variant (3)
Setting Hindering Communication difficulties & lack of Typical (13)
interpreters
Improvised space Variant (4)
Supportive Work outside of private practice Variant (10)
Co-Therapy Variant (10)
Group Therapy Varian (9)
Cultural mediator Variant (9)
Working in Portuguese Variant (7)
Use of technologies Variant (4)
Approach Hindering Trap of “assistancialism” & overinvolvement Typical (12)
Having to adapt traditional approach Variant (3)
Cultural camouflage Variant (3)
Supportive Truly listening & being present General (18)
Flexible & adaptive Typical (15)
Support strengths & autonomy Typical (14)
Work outside the psychotherapeutic realm Typical (14)
Non-verbal methods Variant (8)
Address meaning & identity questions Variant (7)
Long term psychotherapy Variant (7)
Working on here & now Variant (3)
Brazilian context (BC)

All therapists referred to the BC as a struggle for the psychotherapy with refugees: They
perceived the country to be unprepared to receive and integrate refugees. Furthermore, participants
typically highlighted the general lack of funding and communication within the mental healthcare
system and the difficulties in accessing mental healthcare for refugees.
It was very hard to get in touch with the reality of public policies in Brazil, the social reality. I think it
becomes very obvious and very bleak, the unpreparedness that Brazil has to receive immigrants. So, I felt
myself hitting walls, everywhere I ran there was a wall […] so it's very tiring, it's exhausting. It is even a
bit sickening, working here with all the limitations and there are limitations that are so much worse
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concerning the issue of immigration, the specificities of immigrants, of rights […] this is a challenge that
escapes the very comfortable field of psychotherapy. (07)
Patients’ context (PC)

A typical theme concerned the unmet basic needs of patients (food, housing) which,
together with the high legal and economic instability, led patients to have other priorities rather
than attending psychotherapy and thus hampered regular therapeutic meetings: “You can't talk about
the trauma because you're there in a very perverse reality” (02). More than half of the therapists also
described how the discrimination patients were experiencing, along with constant bureaucratic and
integration difficulties, hindered progress in the psychotherapeutic process. A variant hindering
element for the therapy consisted of the separation of patients from their families, patients’
subsequent feelings of isolation as well as the lack of reparation for experienced injustice.
Positive counterparts of these hindrances included supportive factors such as basic needs
being met, increased stability, reparation for injustice and patients’ inclusion in the Brazilian society.
A variant supportive theme was social contact to Brazilians and to people from the patients’
country of origin.
A refugee doesn’t want others to feel pity. I'm sure he prefers opportunity. He wants to be able to work, to
study, to be in school, he wants to be able. The refugee comes in search of possibility. Because in the country
that he left it was impossible to live. So, I think that's what improves the refugee's mental health: Access.
(05)
Therapists’ context (TC)

Therapists stated that working on a volunteer basis and dealing with a high number of cases
limited the time they could dedicate to each patient. It also reduced their opportunities to exchange
with other professionals and to learn about their patients’ cultures. While conflicts in teams
complicated their work, working alone was also perceived as a hindering element, as it increased
the burden and the sense of responsibility they felt. Some therapists felt unprepared and not trained
for the work, especially those whose training did not address social issues or culture, but whose
studies had rather focused on “traditional” psychotherapeutic work: “Where I studied, it was very
hegemonic. Not at all concerned with cultural issues and socio-political suffering. So, all of this was very new to me.”
(16)
Before my job was […] much slower work. It was a much deeper job. To deal with the defence mechanisms,
to look for all that, to help people find answers. Now you don't have time to look for answers. You don't
have time. People are suffering here, they're suffering now. What to do with this suffering in 50 minutes?
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So, it's kind of frustrating on many levels. I learned to do it one way and now none of what I learned
applies. (17)
Typically, being inserted in and receiving support by interdisciplinary networks countered

the feelings of being overburdened, enabled referral and the continuous treatment of patients in
collaboration with the healthcare system and other public institutions. Similar reasons were given
for the helpfulness of teamwork: it allowed for multiple perspectives on cases, therapists feeling
supported, and learning from more experienced professionals.
I think the first [helpful aspect] is our team. Our team, it's very united, very engaged. So, you receive a very
difficult case, that usually is every case, but there are some that are more [difficult], then you know you will
have a clinical meeting with your team that will listen to you and we will think together about what to do. I
think that having a group of professionals in this area helps a lot. Because then there is always someone who
will think of something. A solution emerges. (18)
Psychotherapists typically also stressed supervision, help from their own psychotherapist,
various personal strategies (e.g. writing and sports), and university education in cultural psychology
as supportive elements. The last factor was mainly considered to be relevant by the participants
who had studied at a university in Brazil that offered specialised training in ethnopsychiatry and
intercultural psychology. These participants felt that such training increased their awareness about
global socio-political contexts, which in turn, prevented them from being overwhelmed when
seeing the structural challenges facing patients. The intercultural education also trained them in
cultural humility and engaging with cultural differences with openness and curiosity.
Patient (P)
Therapists saw patients’ mistrust as a variant hindering element. It complicated the therapy,
especially at the beginning, but was seen as understandable considering the patients’ past
experiences and unfamiliarity with psychotherapy. Patients’ difficulties in talking about their
suffering was a rare theme.
[…] especially in the very serious cases, and the most serious ones do not even mean a psycho-diagnosis, it is
only more serious in the sense that they are more distrustful of any human contact, sometimes with sufficient
reason. He had his whole family murdered in front of him and he managed to escape. Or in his country he
is no longer recognised as a citizen, he is persecuted, he has to flee. He has every reason to be suspicious of
human contact. So, the more distrust they have, I think, the harder the job is. (05)
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Patients’ resilience and strengths, as well as the desire to talk about suffering and to engage
in the therapeutic process were thematised as supportive characteristics in patients:
At the end of a two-year trajectory, she is enrolled in the university, manages to have a life project, and to
reorganise herself again. She says: ‘Look, I've learned a lot from all the difficulties I've experienced. I ended
up being a much stronger person, who is much more capable today of facing much more difficulty than before,
because I had to absorb all of those impacts and work through those impacts.’ There is a particularity in
each story about how to relate to the trauma. It involves the resources of each individual, social and financial
resources, specific to each subject. (14)
Therapist (T)
Of all themes, therapists’ attributes were referred to most and by all participants. Typically,
therapists described struggling with getting overwhelmed by continuous exposure to traumatic
stories, by having to juggle too many responsibilities and by becoming aware of the structural causes
of patients’ suffering. Furthermore, some therapists saw feelings relating to power and impotence
as hindering: they experienced powerlessness in the face of their patients’ problems, but also felt
in a position of power due to the patients’ high degree of vulnerability, and struggled with admitting
their impotence as this would de-idealise and compromise the patients’ image of them:
They will ask for everything. Everything is always denied. The doors are so closed, so when you open one,
the person thinks she will find everything in there. So, it’s not easy. For us, it’s not easy too, because you
have to deal with the powerlessness. You say: ‘I can’t offer everything.’ So, I have to reduce expectations, de-
idealise. To her, I won’t be as potent…I will be a person who can offer some things, but not others. (13)
Overcoming ethnocentrism was also seen as difficult, insofar as it required becoming aware
of one’s own cultural shock and not acting on presumptions or falling into moralising behaviour
when encountering cultural differences.
Most comments concerned supportive characteristics of therapists such as the importance
of cultural decentring and humility, which was in turn explicated as becoming aware of one’s
culture, decentring from one’s own values, questioning knowledge, having a non-judgemental, not-
knowing attitude, and being open to patients’ worldview and proper cultural ways of healing. The
theme also comprised an attitude of respect for otherness and cultural sensibility. Secondly,
therapists found it helpful to show awareness of patients’ political and contextual situation by
studying the geopolitical contexts of flight, and to understand patients’ social position in Brazil and
in their country of origin. Thirdly, the importance of theoretical decentring – in other words, being
open-minded and not rigid in terms of content and process of the therapy – was typically stressed,
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as the work seemed rarely predictable. Fourthly, therapists typically referred to an authentic interest
in patients as well as a strong dedication to the work as essential requirements for therapeutic
success: “…you have to like it, you have to believe in it and you have to dive into it, dedicate yourself to it because
it's often not just a nice job in the doctor’s office.” (08) Finally, some therapists stressed self-awareness,
including the awareness of their limits and of situations that evoked their anxiety.
Relationship (R)
Various therapists described bonding with refugee patients as difficult due to patients’
mistrust, cultural differences or unfamiliarity with psychotherapy. Typically, they also saw a risk of
getting overly involved due to the patients’ high degree of vulnerability, or of over-identifying with
patients, which would potentially lead to a dependency relationship or hinder a not-knowing
attitude.
I am challenged not to let me get carried away by my emotions, because I know what they go through,
because I also have experienced this: new job, feeling lost, not knowing how things work, not knowing how
to speak the language. I think that my challenge is not to get overly involved and not let my personal side
enter too much. (08)
At the same time, many psychotherapists referred to the relationship with their patients as
the most supportive element of the therapy and stressed how “being and remaining there” gave patients
a sense of stability that was missing in their current situation: “Most essential of everything is the bond.
Without the bond established, the psychotherapy does not occur” (14). Trust was regarded as crucial and as
strengthened by transparency, by stressing confidentiality, and by confirming patients’ needs.
Speaking the patients’ languages, showing an active interest in patients’ cultures, and having passed
through similar experiences as patients were all seen as supportive for the bonding process.
However, the existence of similar experiences was also discussed as a risk for overidentification.
Similarly, while clear relationship boundaries were supportive to some, others preferred a more
flexible understanding of the relationship, rejecting the position of neutrality of the therapist.
Setting (S)
A variant hindering element was having to improvise the physical space of the therapy since
no established structures existed.
I dream, maybe I'm being whimsical and pretentious, but having a cute little room permanently ready to
attend them with various chairs, maybe a table in the centre. Because here it's always that thing: moving a
chair to one side, moving a chair to another. An improvisation many times. (06)
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Typically, psychotherapists also described the lack of interpreters as hindering, as it led to

problems in communication with patients.
Working outside one’s own practice was seen as helpful by most. It was achieved especially
by visiting refugees at home, talking to them in corridors, accompanying them to events, and by
visiting other relevant institutions. Secondly, therapists typically stressed group therapy and co-
therapy as supportive. Group therapy enabled a symbolic family representation and allowed
patients to create alliances and gain diverse perspectives on their problems. However,
psychotherapists also reported that some patients were at first reluctant to take part in group
therapy and preferred individual treatment. Co-therapy, defined as the presence of more than one
therapist in a session with a single patient, was perceived as supportive for therapists, because the
presence of others in the setting and debriefing after sessions counteracted therapists’ feelings of
being overwhelmed. It was also described as allowing for multiple perspectives on cases: “The co-
therapy setting helps a lot as it enables a lot of perspectives with people who had intercultural experiences already. To
see that what the person is talking about can be understood in different ways when cultures are different.” (06)
Lastly, while some participants stressed the importance of working with interpreters or
cultural mediators, others found it helpful to conduct therapy in Portuguese, allowing patients to
discover a sense of language capability in a secure space. Some described communication
technologies as usefulness for dealing with language difficulties.
Approach (A)
With respect to their approach to the therapy, psychotherapists firstly reported struggling
with the “trap of assistancialism”, i.e. the desire to help patients immediately with everything:
That's something we find challenging and we're very concerned about – being aware of our place and trying
to distance ourselves from the patient. When the subject builds up these literal demands, such as ‘I need a
coat or a plate of food’, we understand that this is super important because these are survival needs. But we
try to understand that we are not the ones who are going to offer it. Precisely so as not to create a
relationship of dependence between the patient and us. (16)
Secondly, when taking culture into account as important consideration in their approach,
psychotherapists thematised cultural camouflage – that is, the risk of overlooking patients’
psychological problems – as a hindering element. Thirdly, few found it difficult to adapt their
traditional therapy to refugee patients’ needs.
At the same time, this adaptation was typically seen as supportive and realisable through
listening to patients’ needs before intervening, and flexibly co-constructing the process.
Furthermore, stepping out of the psychotherapeutic realm of their work was highlighted as
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supportive: 13 therapists directly addressed the need to assist patients in non-psychotherapeutic

ways, reconceptualising their work as clinical-political:
Many psychologists here have this idea that: ‘in the therapy we treat emotions, affections, feelings.
Everything that is outside – housing conditions, education or social oppression – is not clinical. All that is
for politics.’ We believe in the contrary: that a clinic has to be attentive to political questions to be effective.
The cure does not only pass through feelings or emotions. It passes through the social conditions which form
the structure for the person to build upon. (12)
Others referred more indirectly to the supportive function of working outside the
psychotherapeutic realm, such as by stating to engage in advocacy in order to better patients’
context. In their approach, participants furthermore stressed the importance of focusing on
patients’ strengths and supporting their autonomy, for instance by connecting them with public
institutions. Providing a space for elaborating on suffering, being truly present and listening to the
patient were generally regarded as supportive. As a variant theme, non-verbal methods (e.g. art
therapy) were seen as facilitating bonding and supporting patients’ self-efficacy. Addressing
questions of identity – for instance by stimulating conversations about the patients’ countries of
origin – was thought of as helpful, as was working on the here and now. Finally, the benefit of
long-term therapy was thematised as establishing continuity and enabling the formation of a good
working alliance.
Many of the themes are linked across levels. Three of the most apparent links are
represented in Figure 17: firstly, represented by the upper part of the figure, therapists perceived
that refugees’ enormous contextual problems create uncomfortable feelings in themselves,
potentially leading to their overinvolvement (negative experiences depicted on the left side in red).
This makes structural competence and collective work to “share” and “transfer” responsibility and
for social support utterly important, as represented on the right side in green. Likewise, adaptation
to refugees’ needs, which sometimes means going beyond the psychotherapeutic realm, was seen
as supportive to meet contextual challenges. Secondly, and looking at the middle part of the figure,
culture and language differences can be hindering elements, especially due to therapists’
ethnocentrism, but can be overcome, for instance by working with interpreters, receiving training
in cultural psychology and practising cultural decentring and humility. Thirdly, the lowermost part
of the figure shows that establishing a trustful relationship, despite being potentially difficult and
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lengthy, is a central supportive element of the therapy facilitated by a desire to attend patients,
speaking their language and being truly present.
Figure 17
Connections of themes across levels
Discussion
The present study found that psychotherapists working with refugees in Brazil experience
supportive and hindering elements in their work on eight levels ranging from the individual to the
broad societal context. This supports the assumption that important factors for the effectiveness
of psychotherapy outcomes are not limited to the psychotherapeutic approach and method, but
rather include characteristics of therapists and patients, their relationship and the context in which
the therapy takes place (Aveline, 2005; Drožđek, 2007; Wampold & Imel, 2015). The three main
aspects across levels will be discussed here in regards to the scientific literature.
The therapeutic relationship

The therapeutic relationship was perceived by many therapists as the most important part
of the therapy supporting the argument that collaboration and therapeutic alliance, as elements of
the therapeutic relationship and common factors among therapy approaches, consistently predict
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better outcomes of psychotherapy (Aveline, 2005; Barber, 2009; Wampold & Imel, 2015; Zilcha-
Mano, 2018). Hence, as highlighted before, the importance of trust in the relationship became
apparent, as did the struggle to overcome patients’ initial mistrust, arising inter alia from trauma,
stigma of psychotherapy and experiences of discrimination (Duden et al., 2020; Codrington et al.,
2011; Sandhu et al., 2013). By emphasising the importance of the relationship and the difficulties
in overcoming patients’ mistrust, this study might provide a rationale for long-term treatment
approaches. However, it is important to note that most of the participants in this study had a
background in psychoanalysis which may have directed their focus to the therapeutic relationship
and long-term treatment (Doran, 2016). Studies have shown, that if therapists’ attention is drawn
to the alliance, its effects on the psychotherapy outcome increase (Zilcha-Mano, 2018). Therefore,
one might conclude that the importance assigned to the therapeutic relationship is circular: insofar
as therapists perceive it to be essential, it becomes essential. However, the empirical support for
the importance of the therapeutic relationship in general, and in work with refugee patients in
particular, is paramount and includes studies focusing on diverse therapeutic schools such as
cognitive behavioural therapy (Mirdal et al., 2012; Vincent et al., 2013).
Flexible and collectivity-based responses to contextual challenges

In line with Drožđek (2007), therapists stressed the importance of considering the influence
of social determinants on mental health rather than focusing purely on the inner-psychological
problems of patients, making therapists’ contextual awareness or structural competence (Metzl &
Hansen, 2014) necessary. In the Brazilian context, predominant challenges consist especially in
discrimination of refugees (Knobloch, 2015), in the unpreparedness of the system to integrate
refugees and the resulting instability (Bógus & Rodrigues, 2011), and in the lack of funding for
mental healthcare in general and for services specialised in refugees’ needs in particular (Doniec et
al., 2018; Jubilut, 2006). The lack of funding and services also becomes apparent from the fact that
none of the interviewed psychologists worked with refugees as part of the public healthcare system.
Instead 14 participants treated refugees on a voluntary basis without receiving payment, three were
supported by universities, and one by an international NGO.
Consistent with findings from other countries, therapists reported feeling overwhelmed
and helpless in light of the contextual problems of their patients (Apostolidou, 2015), but they also
described how such feelings could be overcome by reconceptualising their work as clinical-political
and by applying strategies outside the traditional psychotherapeutic realm, such as advocacy. It
remains a debated issue whether psychotherapists should intervene in patients’ social or political
context. In Brazil, this debate relates to the differentiation between “traditional” clinical work
(clínica tradicional) and “extended” clinical work (clínica ampliada). The latter type of clinical work
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is somewhat opposed to “the cornerstones of the majority of Western therapies” (Patel, 2003b, p. 221)
namely abstinence and neutrality, as well as the dominant view in traditional psychology which
revolves around individual and isolated work (França Gomes & Dimenstein, 2016). Defenders of
neutrality in the therapeutic space postulate that psychotherapy works best when therapeutic
expertise only, and not values of therapists are employed (Fife & Whiting, 2007). However, it has
been argued that adopting a completely value-neutral position in psychotherapy is impossible (Fife
& Whiting, 2007; Yamamoto, 2012) and might risk marginalising patients even further (Jordan &
Seponski, 2018). Moreover, “traditional” clinical work might imply a rigid, technical and biomedical
perspective. On the other hand, “extended” clinical work, even though it might take into account
the multidimensionality and complexity of mental health problems, might dismiss valuable
technical and specialised knowledge (Marsillac et al., 2018; Yamamoto, 2012). The present study
supports the view that, in the work with refugee patients, political and psycho-social engagement
constitutes a balancing act for therapists: working with patients’ context might lead to therapists’
overinvolvement and thus counteract the goal of nurturing patients’ independence and self-efficacy
(Codrington et al., 2011; Kronsteiner, 2017), hence jeopardising the therapy (Apostolidou, 2015).
In addition, it might increase the risk of psychotherapists becoming overwhelmed by patients’
complex needs and thus losing the capacity to work effectively (Kronsteiner, 2017). On the other
hand, socio-political engagement of psychotherapists can be viewed as an expansion of the
therapist’s professional role (Drožđek, 2007), facilitating trust and bonding (Karageorge et al., 2017;
Watters, 2001), and even as ultimately necessary when psychotherapy is not prioritised by patients
since basic needs are not met (Apostolidou, 2015; Codrington et al., 2011). Indeed, much of the
literature on mental healthcare of refugee patients shows that addressing refugees’ complex
contextual and social needs through psycho-social work, advocacy and practical assistance seems
especially helpful to patients and staff (Duden et al., 2020; Carswell et al., 2011; Codrington et al.,
2011; Karageorge et al., 2017; Watters, 2001).
A potential solution to this balancing act consists in using multidisciplinary teams involving
various professions such as social workers and advocates as well as collectivity-based strategies to
support psychotherapists from feeling overwhelmed by patients’ complex needs (Apostolidou,
2015). In line with ample research, participants in the present study highlighted the need for
support structures for therapists such as their own psychotherapy and supervision, as well as the
helpfulness of collectivity-based strategies in the therapy with refugees (Duden et al., 2020;
Barrington & Shakespeare-Finch, 2013) as for example teamwork, co-therapy (Pocreau & Martins-
Borges, 2013), networks, and group therapy (Duden et al., 2020; Drožđek, 2007). This focus on
collectivity may not be surprising considering the fact that Brazil is the founding country of
community therapy and its healthcare system is committed to social and community issues (Paim
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et al., 2011). It is possible that, in the Brazilian context, relationships with others serve as an
indicator of well-being, and collective concepts of mental well-being and healing are more common
(Kirmayer, 2007). However, group settings have also been favoured by others in work with refugees
(Duden et al., 2020; Drožđek, 2007) as connecting to people in similar situations might facilitate
the adaptation to a new environment and thus better mental well-being. Collective settings
involving more than one therapist as well as therapists’ insertion in interdisciplinary networks may
also lessen the burden on individual therapists and consequently improve their ability to truly listen
to patients and be fully present in the therapy.
Language, culture and psychotherapists’ training

The importance of language, translation and cultural mediation, thematised by participants
in the present study, is widely recognised in research (Miller et al., 2005; Mirdal et al., 2012).
However, in this study, only two of the 18 participants had sporadic access to interpreters. Many
compensated for the lack of interpreters with their own language skills or by attending patients
who already had knowledge of Portuguese, which naturally restricted the group of people
professionals were able to attend.
As ways of dealing with cultural differences, participants in this study stressed theoretical
and cultural decentring and humility as central elements. Cultural humility has been found to be a
predictor for a good therapeutic relationship and for positive therapy outcomes (Hook et al., 2013),
and it has been described as a more flexible, adaptive alternative to knowledge-based cultural
competence concepts. Knowledge-based concepts are a first step to highlight the importance of
cultural factors in psychology, but risk to essentialise cultures (Kirmayer, 2012b; Tervalon &
Murray-Garcia, 1998). In line with this, the therapists in the present study highlighted that, more
than studying patients’ cultures, they needed to continuously decentre their own values and
theoretical assumptions, which was facilitated by supervision, genuine interest in patients’ country
of origin (Drožđek, 2007), and training in cultural psychology. Education in cultural psychology
becomes increasingly relevant for psychology curricula in universities internationally (Griffiths,
2001; Knobloch, 2015; Silva-Ferreira et al, 2019), as the world is experiencing a growing number
of refugees and as claims about the universality of psychological phenomena receive more critical
appraisal (Henrich et al., 2010). Addressing the cultural traditions of thinking about human nature,
about mental health and about therapeutic approaches in the education of psychologists from an
early stage onwards (Christopher et al., 2014; Kirmayer, 2012a, 2012b) could enhance self-
reflexivity of psychotherapists regarding their own theoretical and cultural standing (Kronsteiner,
2017; Tervalon & Murray-Garcia, 1998). Additionally, therapists should be trained to express
cultural humility, for example by demonstrating openness to patients’ cultural worldviews (Hook
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et al., 2013) and recognising patients’ beliefs and alternative sources of help (Kirmayer, 2004; 2012).
Moreover, preparing therapists for the work with refugees might require a focus on structural
competence (Metzl & Hansen, 2014), in other words, supporting therapists’ general socio-political
awareness (Jordan & Seponski, 2018), sensitising therapists to the specific contextual and post-
migration issues faced by refugees (Griffiths, 2001; Watters, 2001), and encouraging their reflection
about how patients’ suffering and the psychotherapeutic process are shaped by the larger structural
context in which they take place (Metzl & Hansen, 2014). In doing so, education programmes
should avoid broad generalisations and stereotyping (Watters, 2001) as well as rigid adherence to a
theoretical orientation (Castonguay, 2011) and instead foster integrative approaches, an attitude of
flexibility in therapists and an openness to explore and repond to the particular background,
context and views of each refugee patient (Savic et al., 2016).
Limitations
The present findings are limited by the fact that we only obtained therapists’ perspectives.
Future research should take into consideration the experiences of refugee patients in Brazil, as this
might provide insights into further supportive and hindering elements in the therapeutic process,
including potential discrimination by therapists. It might also provide the possibility to evaluate
whether patients themselves find group settings as helpful as therapists do. Another issue concerns
the systematisation of patients’ records. Since many of the participants in the present study worked
on a voluntary basis and did not routinely keep records on their patients, the present study could
not provide data on how many patients psychotherapists saw on average nor on therapy duration.
Future studies are needed to provide more systematic and contextual information in this regard.
Such studies may be of great benefit not only to the scientific community, but also to support the
Brazilian healthcare system, which has been described as struggling from lack of
interconnectedness and systematisation (Böing et al., 2009; Marsillac et al., 2018). Furthermore, the
results of this study included frequency counts, a debated issue in qualitative research. Frequency
does not necessarily represent the importance of themes since participants might have various
reasons not to refer to a theme (Braun & Clarke, 2019). Finally, the primary researcher of this study
is German which, given the history of colonisation, may have limited the extent to which
participants in Brazil felt comfortable to articulate their point of view (Watters, 2001). However,
the research team also included Brazilian researchers, and care was taken to establish rapport with
participants through prior informal conversations and transparency, and the interview questions
were formulated very openly.
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Conclusion
In conclusion, psychotherapy with refugees seems to be an emergent issue in Brazil. It faces
many structural challenges, as does Brazilian healthcare in general, especially in light of recent
political developments that indicate a move away from the unified healthcare system (Doniec et
al., 2018). Psychotherapeutic work in this field certainly needs to receive higher appreciation
considering, for instance, the fact that most of the psychotherapists in the present study worked
on a voluntary basis with refugee patients. On a wider level, more policies and better
implementation strategies for the integration of refugees are urgently needed, as is the creation of
interdisciplinary networks to attend the diverse needs of refugees appropriately. With respect to
the education of psychologists and psychotherapists, universities should shift from a
unidimensional psychotherapeutic education (Castonguay, 2011) to fostering integrative
approaches, theoretical decentring and the structural competence, flexibility, open-mindedness and
cultural humility of therapists. Internationally, taking the perspectives of Brazilian psychotherapists
into consideration might help to develop a more collectivity-focused and contextual understanding
of mental health and therapeutic processes and thus advance investigation and application of
community- and network-based approaches for bettering the mental health of refugee patients.
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Section III
An Integrative Discussion
If people were not different,
they would have nothing to say to each other.
And if they were not the same, they would not understand each other.
(Hannah Arendt, 1958, p. 155)

Chapter 8
Summarizing and Integrating the Results
Section III | Chapter 8 Integrating the Results
This chapter will firstly provide short summaries of the findings of the Qualitative Evidence
Synthesis (Study 1), and the fieldwork in Brazil (Studies 2-4). Subsequentially, these findings will
be integrated by comparing and contrasting them and linking them to the scientific literature.
Summaries of the Results
Section I – A Qualitative Evidence Synthesis
Chapter 2 | Study 1 and Chapter 3
Speech is civilization itself. The word, even the Those who know do not talk.
most contradictory word, preserves contact – it And talkers do not know.
is silence which isolates.
Thomas Mann (1972, p. 796) Lao Tzu (2001, Ch. 56, p. 109)
Chapter 2, the QES of 10 qualitative primary studies was Study 1 of this dissertation and
showed that mental health professional and refugee patients experienced particularly four elements
as positive and helpful in the MHSR. They
1.) saw the therapeutic relationship and trust as key to successful work,
2.) felt that adaptive approach and psychoeducation worked best,
3.) and highlighted the need for cultural sensitivity in professionals as well as psychosocial
work and advocacy on behalf of client.
4.) Mental health professionals additionally stressed support structures for professionals such
as supervision as utterly important.
As negative and hindering another four aspects were highlighted by both groups. These aspects
concerned
1.) the missing mental healthcare structures,
2.) the external instability of refugee patients, i.e. their basic needs not being met and their
asylum application not determined.
3.) Furthermore, cultural and language differences were described as hindering, as well as
4.) a high level of mistrust in patients due to previous negative experiences with institutions,
discrimination as well as mental health stigma.
Finally, the synthesis showed four major categories of ambivalent accounts in both groups.
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1.) Talking therapy was sometimes described as relieving, sometimes as not adequate or even
as useless.
2.) Trauma exposure was seen as a necessary part of the therapy by some and as too painful
and potentially harmful by others.
3.) Some participants questioned the benefit of psychotherapy for refugees, stressing that
refugees had more immediate and practical problems and thus could not focus on
psychological concerns. Others perceived therapy as a stabilising factor and particularly
useful in patients’ instable and uncertain contexts.
4.) Finally, mental health professionals uttered ambivalent opinions regarding the impacts of
this work on professionals with some describing it as adding meaning, others as evoking
vicarious traumatisation.
Chapter 3 shed some light on the methodological challenges of conducting a qualitative
evidence, particularly on the challenges of abstracting from primary studies while maintaining the
in-depth meaning of participants’ experiences and of attempting to include primary studies from a
diversity of countries. The chapter broad attention to differences in intellectual and writing styles
that exist internationally and that may impact how meta-researchers evaluate primary studies.
Section II – Fieldwork in Brazil
Chapter 5 | Study 2 – The psychological suffering of refugee patients in Brazil
Distinct from the QES and the following two fieldwork studies in Brazil, the focus of Study
2 was an investigation of the background and psychological suffering of refugee patients in Brazil.
This part was thought to acquire some context to the following investigations, as there are very
few studies providing this sort of information on refugee patients in Brazil (Teixeira et al., 2013).
In terms of countries of origin (CoOs), the 32 participants mentioned to work most
frequently with refugee patients from Venezuela and Haiti. This is in line with the report of the
National Committee of for Refugees in Brazil, showing that most asylum applications in 2018 came
from Venezuelans (77%: 61.681) and Haitians (9%: 7.030; CONARE, 2019). Other countries
mentioned by more than five participants included Syria, Colombia, the Democratic Republic of
the Congo (RDC), Argentina, Angola and Uruguay. In official Brazilian statistics, Syrians were on
8th place in terms of numbers of asylum applications in Brazil in 2018, and the group that received
most often official refugee status in Brazil, forming 40% of recognised in Brazil from 2011 to 2018
(CONARE, 2019). People from the RDC formed 14% of recognised refugees in the same time
period (CONARE, 2019). In our study, other countries of origins described by more than two
participants were Guinea, Cuba, Paraguay, Bolivia, Capo Verde, Nigeria, Peru, Mozambique, Mali,
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Chile and Senegal. Certainly, the countries of origin mentioned by participants are not necessarily
linked to the official and total numbers of refugees in Brazil from these countries. Rather,
psychologists may see patients from a certain country more frequently due to reasons such as the
location of the work setting (e.g. in Roraima treating Venezuelans as a psychologist is very likely),
the help-seeking behaviour in these groups or their access to MHSR (e.g. language). For instance,
it is not surprising that many participants mentioned many Latin-American countries as origin of
their patients, since also 17 participants indicated being able to work in Spanish language, in
comparison to only two participants who treated patients also in Arabic.
The study furthermore showed that while participants did describe some common
symptoms and disorders in their patients (depression and grief most frequently, followed by anxiety
and post-traumatic stress disorder and symptoms), criticism of psychiatric diagnostic manuals such
as DSM-5 or ICD-10 was prevailing. The diagnostic classification systems were often considered
as depicting a Western perspective on suffering only, as not adequately representing patients’
experiences or as medicalising and individualising the suffering which participants perceived largely
as socially caused.
Thus, instead of using psychiatric diagnostic classifications, four different themes of
patients’ suffering, that incorporated to a large extent a social dimension, were described. Firstly,
all participants stressed the post-migration context as a cause of substantial suffering in their
patients. They referred particularly to xenophobic attitudes and rights violations, to the social
isolation of patients, to processes of cultural adaptation and to patients’ precarious economic
situation. Secondly, psychologists talked about the traumatic experiences their patients had faced
or were still facing. Thirdly, as a main element of patients’ suffering, psychologists described the
life ruptures that were implicated in the flight being and linked to many losses and sometimes to
the experience of an existential crisis. Finally, participants stressed the current situation in patients’
CoOs as related to patients’ suffering. Participants highlighted that for many patients their suffering
revolved around worry about their families who had to remain in the CoOs, around guilt of leaving
them behind and around not receiving reparation for the injustices they had experienced in their
CoO.
Chapter 6 | Study 3 – Psychologists’ experience of providing psychological care for

refugees in Brazil
The following two chapters of fieldwork of this thesis looked at the experiences of
psychotherapists and psychologists in providing MHS for refugees. In Chapter 6, Study 3 of this
dissertation, the results from 14 interviews with psychologists who provide “acolhimento psicológio”
(psychological care) for refugees in Brazil showed that this group experienced their job as one that
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went beyond classical psychological tasks, since it was happening in an emergency-like situation.
They also perceived the work with refugees to be a completely new field in Brazil, and to involve
a high degree of personal closeness to their patients.
In terms of positive aspects, professionals described how they gained new perspectives
from their work, were inspired by seeing their patients’ resilience and transformation and fulfilled
by the possibility to make a difference through their work. As negative aspects they perceived the
lack of mental healthcare structures in Brazil, the commonly resulting staff fatigue, the missing
competencies and experiences of healthcare professionals of working with refugee patients’ in
general. Participants also reported on the high levels of xenophobia their patients were
experiencing. As facilitators, psychologists outlined the necessity to remain open and flexible in
their work, to tolerate a high level of frustration, and to display transparency, warmth and
authenticity towards their patients. Furthermore, they considered it helpful to focus on fostering
patients’ emancipation, providing safe spaces and to work with groups of patients. Psychologists
also highlighted the essential role of support structures for themselves such as supervision.
In terms of necessary changes to better the MHSR in Brazil, psychologists thought that a
more social perspective was needed in Brazilian mental healthcare in general, i.e. one that focused
on patients’ context and valorised social work, instead of individualising and medicalising patients’
suffering. Participants also stressed the need for more state structures and support for the
integration of refugees on the one hand, and for mental healthcare services in general on the other
hand. As a final aspect, participants called for a conscientisation of the Brazilian population
regarding the refugee situation and regarding cultural differences, in order to reduce levels of
xenophobia in the population and induce a shift in the public perception towards an appreciation
of differences.
Chapter 7 | Study 4 – Psychotherapists’ experience of psychotherapy with refugees in

Brazil
Chapter 7, the fourth and last study of this dissertation was an analysis of 18 interview
transcripts with psychotherapists in Brazil. It showed that these professionals were experiencing
helpful and hindering aspects in the psychotherapy with refugee patients on eight levels ranging
from the individual competencies of therapists to the Brazilian context.
Three themes were prominent across those levels in the data. Firstly, participants
highlighted how the Brazilian context and patients’ post migration situation posed problems to the
therapy with refugee patients. For instance, they outlined feeling overwhelmed and helplessness
when confronted with patients’ contextual problems and needs, as well as getting overly involved
and falling into the pitfall of assistancialism. They described how these struggles could be addressed
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and overcome by support structures for professionals, by working with groups of patients and in
networks of professionals, by developing structural competency, by working outside the typical
realm of psychotherapy and by flexibly adapting approaches to patients’ needs.
Secondly, cultural and languages differences in the work implicated challenges for
professionals, such as feeling untrained, having to adapt their therapeutic approach, facing their
own ethnocentrism and risking cultural camouflage, as well as dealing with the lack of interpreters.
In order to deal with these challenges, psychotherapists stressed the importance of their own
cultural decentring and cultural humility, of an education and training in cultural psychology, of
fostering a work with interpreters and of making use of non-verbal methods.
Thirdly, a trustful therapeutic relationship was considered essential for the psychotherapy.
Meanwhile, it was seen as difficult to establish due to aspects such as psychotherapists’
overidentification with patients, and a long bonding process which was perceived as caused by the
xenophobia patients experienced in their daily lives, as well as their unfamiliarity with
psychotherapy and generally heightened mistrust. As central elements to overcome these
difficulties in bonding and building trust, psychotherapists described speaking patients’ language,
showing strong interest in patients, truly listening to their stories and being fully and authentically
present in the therapeutic sessions.
Specificities in the Results of the Studies

In each of the studies some new aspects of the experience of the participants emerged. In
Study 1, the QES, results included participants questioning the benefit or sense of the MHSR;
an aspect, participants in Brazil did not refer to. For instance, some participants in the QES,
professionals as well as refugee patients, felt that MHS did not help and was useless in a context
were basic needs were not met. On the other hand, some participants in the QES felt that patients
could regain hope through the mental health support and experience improvements of their
symptoms. Rather than framing the mental health support as useful and beneficial or not,
psychologists in the Brazilian studies talked about ways to improve the helpfulness of the support.
Similar to the participants in the QES, participants in Brazil described the harsh social reality
refugees were facing and how this reality impacted the therapeutic space: “You can't talk about the
traumatic because you're there in a very perverse reality.” (Psychotherapist, Florianópolis, Duden & Martins-
Borges, 2020, p. 7). Participants in Brazil also clearly indicated the limits of MHSR in a context in
which basic conditions were not met:
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I think it is very challenging to think for example... logically the basic, material, survival issues are the first
to come. There is no way. Because if we don't guarantee the existential basics for them, we can't do a psychic
job. There is no way. (Psychologist in Acolhimento, Florianópolis)
However, the recognition of this harsh reality not make participants in Brazil question the use and
benefit of mental health support per se. Many considered instead how the MHS, and particularly
psychotherapy, could be adapted to best serve the needs of refugee patients.
One potential explanation for this difference between the QES and the studies in Brazil
might be that the participants in Brazil were focused in the interviews on describing therapeutic
processes and process improvements rather than therapy outcomes, whereas the primary studies
in the QES included a discussion of outcomes, too. Future research may benefit from taking
refugee patients’ perspectives in Brazil into consideration to determine whether or not they
perceive MHS to be helpful while living in a precarious and challenging post-migration context.
Another aspect unique to the QES were the commonly discussed helpful approaches for
dealing with trauma specifically, such as aiming to construct meaning and to create continuity
for fragmented memories. In the investigations in Brazil, trauma therapy approaches received only
minor attention. Psychologists in Brazil did describe patients’ traumatic experiences and how
professionals might get overwhelmed by listening to numerous traumatic stories. They did not,
however, mention specific approaches to address trauma or discuss trauma exposure at all. While
many participants used the term “trauma” to refer to their patients’ experiences, many were
reluctant to speak about post-traumatic stress disorder (PTSD).
The concept of PTSD is, of course, a product of Euro-North-American culture, context
and history (Kirmayer et al., 2015), but it has reached many realities internationally (Argenti-Pillen,
2000). One might wonder if the fact that participants did not speak of specific trauma treatments
may relate to a concern of contributing to an individualisation of traumatic experiences and to a
neglection of the socio-political context of refugees. Such a concern could relate to the recent
history of dictatorship in Brazil which involved experiences of collective traumas (Kevers et al.,
2016). It could also be seen in light of international criticisms of the PTSD concept (Drožđek,
2007; Kevers et al., 2016; Summerfield, 1999). Another potential explanation for this discrepancy
between the QES and the Brazilian studies might be that psychologists who treat refugee patients
in Brazil are in fact dealing to a large extent with people who suffer from depressive rather than
from PTSD symptoms, due to the long-term effects of profound losses (e.g. of family members,
of their home etc.; Momartin et al., 2004). Additionally, the psychological and psychotherapeutic
orientations may come into play as explanations – specific interventions to address trauma largely
stem from cognitive-behavioural approaches to mental healthcare (Katsonga-Phiri et al., 2019;
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Vincent et al., 2013), for example narrative exposure therapy (Neuner et al., 2004). 44 % of the
participants in Brazil, however, were orientated towards Psychoanalysis or Psychodynamic
approaches, 25 % towards Ethnopsychiatry and 16 % towards Community, Social or Systemic
Psychology. Using specific trauma-focused intervention strategies or techniques may not have been
in accordance with their approaches and participants might rather have followed transdiagnostic
strategies to treat their refugee patients. Furthermore, in Brazil there are no specific and rigid mental
healthcare plans or programmes that prescribe a certain number of sessions or a specific sequence
of steps in treatment per patient or per diagnosis (Böing et al., 2009). This might also make it less
likely that psychologists apply interventions specific to a certain disorder or psychological problem
such as PTSD.
Specific to the Brazilian context seemed to be the novelty of the topic which participants
perceived and the associated extreme unpreparedness of the system to provide an adequate
response. On the one hand, the latter concerned the missing preparation of the Brazilian system to
integrate refugees visible in a lack of public services, support structures and housing. On the other
hand, it related to a shortage of mental healthcare structures and of interpreters in healthcare.
Psychologists in psychological care and psychotherapists described that staff and networks of
professionals were missing, and that spaces for MHSR were still mostly improvised. Due to the
scarceness of resources, professionals found it difficult to develop plans for the mental health
support with their patients. They felt that it would be helpful for the MHSR if there was a build-
up of structures for the integration of refugees, such as language courses and better access to public
services. Furthermore, participants called attention to the need for more mental healthcare
structures in general and for educating professionals in cultural psychology.
A likely explanation for why the novelty of the topic and the unpreparedness of the system
were prominent themes in Brazil, but not to the same extent in the QES is, firstly, related to the
general socio-political problems in Brazil (Barros et al., 2001) that were described in Chapter 4. In
the QES, the work context of professionals seemed to indicate a more comfortable situation – they
worked in Sweden, Switzerland, Germany, Denmark, the United Kingdom and Australia, all of
which are Western and high-income countries whose situation is very different to that of Brazil.
As discussed in Chapter 4 of this dissertation, Brazil faces major structural deficits and a lack of
public policies for the reception, integration and care of displaced people (Bógus & Rodrigues,
2011; Jubilut, 2006; Leão, 2011), for instance with about 37% of displaced people living on the
street after their arrival in Brazil (Aydos et al., 2018). Furthermore, while the Brazilian healthcare
systems aims for a universal healthcare model, the provision and coverage of healthcare services in
general, and mental healthcare services in particular, are limited and are not comparable to those
of countries with universal healthcare systems, such as Sweden (Doniec et al., 2018; Marsillac et al.,
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2018; Savedoff & Smith; 2011). Even though the introduction of the SUS in Brazil was followed
by improvements in population health, still more than half of the healthcare spending is private
and thus, not readily accessible for people with limited resources (Gurgel et al., 2017). The fact that
psychologists in Brazil perceived the topic of flight, migration and MHSR to be a new topic stands
in contrast to the fact that migration in not a new phenomenon in Brazil (Patarra & Fernandes,
2011; Zamberlam, 2004). Meanwhile, many authors have stated that the topic has not yet received
much attention in Brazil and is only slowly beginning to emerge (Aydos et al., 2008; Braga Bezerra
et al., 2019; Teixeira et al., 2013). As a Brazilian psychotherapist, whom I interviewed for my
Masters’ thesis, said:
...Brazil refused, denied his past of migration. When I got here, people would tell me: ‘Ah study migration
for what? This is not important in Brazil. There are no immigrants, no refugees.’ […] So the situation in
Brazil at the moment, I think it's opening up, right? It's not starting. It's like you have a wound that has
never healed but never bothered much either. And then now it's like it's opening up and people realize that
there are migrants and refugees (Psychotherapist; Duden, 2016; pp. 53-56)
In Study 3, psychologists providing “acolhimento psicológico” (psychological care) in Brazil in

particular described the MHSR situation in terms of a chaotic and emergency-like situation in
which everything seemed always urgent and there was a constant increase in demands: “At first it
was a little bit like putting out a fire” (Psychologist in Acolhimento, Florianópolis). In order to deal
with this situation, participants stressed the need for a high frustration tolerance in professionals.
Additionally, psychologists in this study criticised that psychology remained elitist in Brazil, only
accessible to the affluent stratum of the population. They saw this as a main barrier for refugees to
find mental health support.
That these aspects were specific to the accounts of psychologists working in psychological
care, and not prominent among psychotherapists, might be firstly explained by the fact that the
psychologists in psychological care in Brazil tended to see a higher number of refugee patients for
shorter periods of time than psychotherapists. A large quantity and high rate of fluctuation of
patients may evoke feelings of chaos and emergency (Hensel et al., 2015), that are not felt to the
same extent by psychotherapists who treat fewer patients and treat them over a prolonged period
of time. Additionally, the somewhat less predefined professional role of counsellors and
psychologists in psychological care (McLeod, 2003) might make it more likely that these
professionals, apart from dealing with intrapsychic process of patients, also deal with their social
context, in essence integrating aspects of social work into their professional activity. Even though
psychotherapists in this investigation stressed that they needed to be attentive to socio-political
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questions and to work outside the psychotherapeutic realm, many therapists also underscored the
importance of distancing themselves from the patients’ demands:
That's something we find challenging and we're very concerned about – being aware of our place and trying
to distance ourselves from the patient. When the subject builds up these literal demands, such as ‘I need a
coat or a plate of food’, we understand that this is super important because these are survival needs. But we
try to understand that we are not the ones who are going to offer it. Precisely so as not to create a
relationship of dependence between the patient and us. (Psychotherapist, São Paulo; Duden & Martins-
Borges, 2020, p. 9)
In contrast to this, the work of psychologists in psychological care indicated an often greater (over)
involvement and involved tasks that addressed the contextual needs of refugees more directly. This
difference between the studies was meanwhile not clear cut, and many psychotherapists in Brazil,
as well as participants in the QES also reported getting overwhelmed, adapting their approach to
patients’ needs and context, as well as perceiving chaotic and missing structures for the integration
and the MHS of refugees. The topic of the chaotic situation was simply more dominant in the
interviews with the psychologists in psychological care.
A second explanation for this may lie in the fact that five of the psychologists in Study 3
(in comparison to only one of the psychotherapists in Study 4) worked in the north of Brazil, in
the state of Roraima. While being the least populated of the Brazilian states, Roraima received 63%
of all asylum applications in 2018 and serves as Venezuela’s main gateways to Brazil (CONARE,
2019; IBGE, 2019). In contrast to this, the other southern and south-eastern states in which most
of the psychotherapists worked (São Paulo, Paraná, Santa Catarina and Rio Grande do Sul)
received, taken together, only 18% of all asylum applications in Brazil in 2018 (CONARE, 2019).
Psychologists’ descriptions of the emergency-like and chaotic situation may be seen in light of this
context and the fact that, while the state is facing many infrastructural and economic problems and
has a Gross Domestic Product comparable to Burundi (UNDP, 2013), Roraima has experienced
an enormous influx of displaced people from Venezuela recently (UNHCR, 2020). The capital Boa
Vista, for instance, increased in population by 10% in just one year (UNCHR, 2020).
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Commonalities across Studies

In what follows, I outline the commonalities among the findings of the investigations of
this dissertation and place these findings in the context of the scientific literature. The
commonalities, organised in negative/hindering, ambivalent, and positive/supportive elements of
MHSR, are depicted in Figure 18.
Figure 18
An integrative view of positive, ambivalent and negative aspects of the MHSR
Negative and hindering aspects of the MHSR
1.) Patients’ post-migration context
The first major category of negative and hindering aspects in the MHSR relates to refugee
patients and their specific situation. The results of all studies showed that participants perceived
the post-migration situation to be highly problematic for the mental health of their patients and
the therapeutic process in the MHS (see Figure 19).
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[…] the needs that the Venezuelan has when he arrives here. ‘I don't have a home, I don't have a job, I
don't have that, I don't have that’. This is leaving him in a social depression. This social depression that is
caused by the lack of subsidy, of dignity. You don’t have a minimum, you don't even have shampoo.
(Psychologist in Acolhimento, São Paulo)
Figure 19
Patients’ post-migration context
Participants in all studies highlighted that refugee patients’ basic needs often remained
unmet and that patients faced intensely precarious situations. Professionals reported that their
patients had problems with housing, scarcity of food and unemployment, and were concerned
about their future, often due to the uncertainty of their asylum status. In the QES, some
participants even felt that MHSR was useless, and addressing past trauma inappropriate, as long as
patients’ current context remained unstable. Processes of cultural adaptation were mentioned as a
further challenge in the post-migration situation for refugees. Professionals described patients’
struggles with integrating into the host societies, with experiencing cultural shocks and finding it
difficult to establish relationships with the host population. Linked to these struggles with
adaptation, participants in all studies described the social isolation of refugee patients as
problematic in the post-migration situation. This isolation was exacerbated by difficult procedures
or the missing possibility for family reunification. Separation from the family was often perceived
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to result in feelings of loneliness, apathy and sadness in patients, and as also being a burden for
professionals, since professionals came to feel that they were the only stable relationship or network
for their patients. Moreover, the impact of refugee patients’ daily experiences of discrimination,
xenophobia and racism were highlighted in all studies. These negative interactions with the host
population were described as leading to despair and anger in patients, eroding their wish to
integrate, and augmenting their mistrust of people in general and in particular of the population of
the host country, including psychotherapists.
These findings are in line with the scientific literature: Research has shown that adverse
conditions post-flight relate to mental health problems (Kartal & Kiropoulos, 2016; Martins-
Borges, 2013; Porter & Haslam, 2005), such as aggravated PTSD and depressive symptoms (Silove
et al., 2017). For instance, in a study on post-traumatic stress, Bosnian refugees reported daily
hassles, financial troubles, and nostalgia as their worst mental health-related problems (Knipscheer
& Kleber, 2006). Furthermore, cultural adaption is frequently viewed as a cause of substantial
distress in refugees and immigrants in general (Knipscheer & Kleber, 2006; Martins-Borges, 2013,
2017). The impacts of future instability due to temporary visas and long and tedious asylum
procedures on the mental health of asylum-seekers have raised international concerns (Comtesse
& Rosner, 2019; Davidson et al., 2008). Discrimination and xenophobia have been described as
major obstacles to the integration of refugees, are related to the struggle of finding employment
(Moreira & Baeninger, 2010) and greatly affecting the mental health of refugees (Bogic et al., 2012),
sometimes even more than pre-migratory trauma (Beiser & Hou, 2016). Similarly, stressful material
conditions in host countries can predict mental health status in refugees as effectively as, or even
more accurately than, exposure to war trauma (Bogic et al., 2012). A strong link between social
inequality, poverty and mental health disorders has also been stressed for the Brazilian general
population (Silva & Santana Santana, 2012). Experiences of discrimination and daily socio-
economic stress are considered as secondary stressors in Rousseau and Frounfelker’s (2019) model
of the (premigration) and secondary (postmigration) stressors for migrants, which was introduced
in Chapter 1 of this dissertation (see p. 35). Isolation has also been found to be a major stressor in
post-migration settings (Miller & Rasmussen, 2011). Eisenbruch (1991) integrated the loss of a
sense of belonging and of social networks into the concept of “cultural bereavement”, a
characteristic concept of mental health issues following forced displacement (e.g. Bhugra & Becker,
2005). In support of the importance of social networks, associations have been found between the
well-being of displaced people and the reconstruction of their social networks and a feeling of
community (Summerfield, 1999).
To account for the importance of the post-war situation, already in 1979, the German-
Dutch medical doctor and psychoanalyst, Hans Alex Keilson described the concept of “sequential
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traumatisation” (Keilson, 1979, 1991). After conducting an investigation on Jewish orphans who
were hidden by Dutch families during the Second World War, he postulated that there were three
phases of traumatisation:
1. the occupation of the Netherlands and beginning of the terror against the Jewish
population,
2. the direct persecution and hiding; deportation, separation from parents, time in
(concentration) camps,
3. the after-war period.
In Keilson’s view, every phase contributed to the traumatisation of orphans, and the end of the
war did not necessarily put an end to that traumatisation. For these children not only the direct
persecution, but also the subsequent sequence of reintegration was of crucial importance. In fact,
Keilson showed that those children who grew up under relatively good conditions in the post-war
period (third phase) proved to be psychologically more stable or healthier than those who
experienced a difficult third period after a (comparatively) less terrible second sequence. According
to Keilson (1979), traumatisation thus needs to be seen as a process, in which not only a single
traumatic event, but a sequence of events should be considered. The concept of sequential
traumatisation underscores the importance of the post-war conditions and the associated
possibility of breaking through the chain of traumatisation by precisely bettering these conditions.
While Keilson described the idea of sequential trauma some 40 years ago and in relation to the
experiences of Jewish orphans, it is not far-fetched to transfer the concept to the post-migration
(and frequently also post-war) period of refugees. Meanwhile, only recently there has been a shift
in the scientific trauma literature away from a pure focus on past events, towards a recognition of
the accumulative experience of stressors in the past and in the present, in the country of origin and
in the host country (Davidson et al., 2008; Hou et al., 2020; Kartal & Kiropoulos, 2016; Morgan et
al., 2017). Slowly, researchers have come to be interested in how post-migration stressors might
actually interplay with and exacerbate previous traumas and suffering (Cleveland et al., 2014).
2.) Patients’ mistrust
As a further difficulty in the therapeutic encounter, professionals of all studies commented

on patients’ mistrust. Apart from being perceived as a consequence of the experiences of racism,
xenophobia and discrimination, mistrust was described as resulting from a lack of familiarity with,
and information about, psychotherapy and psychological care, from negative prejudice against
mentally ill people and from past bad experiences with official institutions and authority figures.
Professionals in the investigations shared that this mistrust was particularly prevalent at the
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beginning of the therapeutic encounter. They depicted it as a major barrier to forming a therapeutic
relationship and as making the bonding process lengthy and difficult.
The respondents were able to describe what their experiences or perceptions of mental health services were in
their home countries. In general, the adolescents described health services as limited or absent. There was also
distrust of the professionals involved in these services, which may partially account for the limited trust of
refugee services. (Patients; Majumder et al., 2015, p. 5; QES)
The struggle to overcome refugee patients’ initial mistrust and, at the same time, the
importance of developing a trusting relationship, have been stressed in the literature on MHSR
(Codrington et al., 2011; Sandhu et al., 2013; Turner, 1995). A strong mistrust of mental health
professionals, of people more generally and of public institutions has been reported to arise from
traumatic experiences and severe human rights violations (Frey, 2001), from the stigma of
psychotherapy and from experiences of discrimination (Codrington et al., 2011; Franks et al., 2007;
Sandhu et al., 2013; Turner, 1995). Meanwhile, the experiences of discrimination that evoke
mistrust in refugees do not only concern the general population in host countries – research
suggests that refugees, in particular Black refugees and other Black people and People of Colour
are discriminated against in the health and mental health sectors of many countries. For instance,
in countries such as the UK and the USA, Black patients are more likely to receive prescriptions
for medication for mental health problems than White people, and are more often admitted to
hospitals involuntarily and for longer periods of time (Barnett et al., 2019; Lewis et al., 1990;
Littlewood & Lipsedge, 1992). Such discrimination within the healthcare systems has been
highlighted as a further reason for the development of a mistrust of health service provision among
Black refugees (Snowden & Cheung, 1990; Sussman et al., 1987). Racist, xenophobic and
discriminatory attitudes can also be present among mental healthcare providers (Cénat, 2020;
Guzder, 2014; Rousseau et al., 2008). For instance, Mohamed and Smith (1997) suggest that higher
rates of depression and somatisation among Black women in general are actually linked to racism
among providers. Constantine (2007) and Owen et al. (2011) also report patients experiencing
discrimination and microaggressions through mental health professionals, which negatively
impacted the working alliance and the well-being of patients. Therefore, and with the aim of
addressing racism, discrimination and disparity in mental healthcare and to help professionals
provide anti-racist healthcare, a number of guidelines have already been developed by mental
healthcare associations (Cénat, 2020).
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3.) Difficult access and structural limitations of MHSR
Results from the studies showed that participants reported that the access to mental health
support as being problematic for refugees; for instance because they had no means to pay for
transport to reach the places where MHSR was offered, or due to the language barrier and lack of
interpreters. The studies found that participants felt that basic mental healthcare in general, and in
particular specialised care for refugees was missing.
I think there is this public policy issue in the first place. There's now a general dismantling and it's not
only with immigrants and homeless people. The people of Cracolândia with mental health issues… there are
calls to install the asylums again. So, it's in this area of mental health, it's having such an absurd
dismantlement. But the immigrants are the target. I'm sure of it. They will be the target. So, what happens,
not even the CRAI [...] they are going through a very violent crisis. The Christian organsations are also
passing through a crisis. And we need partnerships. So, I receive immigrants and refugees and I have to
send them to get their documents. Then I'll send it to the University of São Paulo, the Law School. They
have a nucleus that does that. So I know I can send them there. But when we're starting to send them there,
it already doesn't exist anymore. Or it doesn't receive people anymore. So we're starting to realize this
disassembly. (Psychotherapist, São Paulo)
Professionals in Brazil and in the primary studies of the QES perceived that there was low
or only little funding for MHSR and professionals were ill-equipped and untrained in areas such as
cultural sensibility, language skills, and structural awareness. Indeed, many professionals were
described as lacking mindfulness for the refugee situation and as being ethnocentristic.
The scientific literature on barriers to access to the healthcare system for refugees in host
countries is extensive. In particular, the problem of how to include interpreters in MHSR has been
outlined, since the coverage of interpreters’ costs remains unclear in many countries (Mewes et al.,
2016; Yick & Daines, 2017) and there is a general lack of qualified interpreters for healthcare
services (Ku & Flores, 2005). Kaya et al. (2018) found, for instance, that in Turkey almost all
participating healthcare providers and health policymakers recommended the improvement of
interpretation services, as language problems were a common barrier to access. Similarly,
psychotherapists in private practice in Germany reported that requesting interpreters and covering
their costs were the greatest barrier to the admission of refugees to psychotherapy, and, at the same
time, also the most important factor to improve the MHSR (Mewes et al., 2016). In the UK, Franks
et al. (2007) also found that a deficit of interpreting services and resources limitations were major
barriers of access to MHS for refugees. Additionally, this qualitative study also reported on
refugees’ lack of trust and of knowledge of services, on their fear of authority, and stigma as barriers
to access. Furthermore, diverging understandings of mental health issues were perceived as a key
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barrier to seeking mental healthcare services (Franks et al., 2007). In a Brazilian study on Bolivian
immigrants in São Paulo, participants reported on instrumental barriers to seeking help, such as
having difficulty in taking time off from work to attend services. Moreover, the authors found
stigma-related barriers, such as the concern of being perceived as weak for suffering from mental
health problems, and finally attitudinal barriers, for example a dislike of talking about own feelings
and thoughts (Bustamante et al., 2019). Meanwhile the investigation by Bustamante et al. (2019)
focused largely on barriers to mental healthcare related to migrants. Participants in the present
dissertation, in contrast, addressed mostly barriers related to structural limitations of MHSR and
professionals’ own limitations in providing adequate care. As Kaya et al. (2018), professionals
described the MHSR as inadequate and difficult to access and saw a need to increase structures by
employing more mental health professionals and by building more specialised migrant health
centres. In the studies of this dissertation that focused on the Brazilian context, the structural
difficulties were particularly pronounced, which is illustrated by the fact that many psychologists
(15 out of 32) worked on a voluntary basis with refugee patients without receiving any funding,
and only four had sporadic access to interpreters. Whilst the training of professionals in providing
adequate MHSR is essential, as will be discussed later on, it seems that no degree of education or
intercultural experience can make up for the lack of the most fundamental structures.
Ambivalent aspects of the MHSR

The studies of this dissertation showed two recurring ambivalent themes: the impacts of
the work with refugee patients on professionals, and the question of the shape of an adequate
therapeutic relationship with refugee patients.
1.) Impacts on professionals
Participants across the studies were convinced that providing MHSR can have profound
impacts on professionals and lead to processes of personal change. All studies found that the work
with refugee patients was challenging for professionals, particularly because it involved many
structural constraints, such as having too many patients and too little time for each one of them,
and because it meant witnessing the hardship refugee patients were confronted with in their daily
lives. A further challenge was the lack of services to which refugee patients could be transferred if
necessary. Consequentially, professionals often felt overburdened and needed to deal with own
feelings of helplessness and frustration. Professionals felt that they could easily get overinvolved
and overwhelmed when attending to refugee patients’ multiple, complex and often practical needs.
Furthermore, participants described being strongly affected by patients’ (traumatic) stories, as well
as overidentifying with their patients, and patients’ feelings of hopelessness:
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I keep thinking...a big challenge for me is: what to do when the person, the patient questions something, and
I think that's something that gets to me very much: My biggest challenge in the therapy is when the patient
says something, that I agree with. That convinces me. The person says one thing: ‘But I won't be able to go
back. No matter what I do here, I'll never be able to go back and they don't do anything to make amends
for what I've been through.’ And so I think ‘Puz...’ that's a conflict for me, that moves me. When
something makes so much sense in me that I stop being the mirror. In the case of the reparation through the
state, for example, it will succeed in violating a person out of nowhere and then I will disorganize myself.
Then it becomes my challenge. I think that my challenge ends up being when I identify too much with the
suffering of the other. I think it's important not to identify so much, you know? And I don’t mean identify
myself in the sense: I've also been through it. But in the sense that what they say makes a lot of sense to me.
(Psychotherapist, Curitiba)
In the QES, these impacts on practitioners were sometimes framed under the term “vicarious
trauma”, i.e. professionals experiencing a type of secondary traumatisation by listening to their
patients’ traumatic experiences. Meanwhile, participants also shared positive impacts of their work
with refugees. For example, they described being inspired by patients’ strength, resilience and
processes of transformation. They felt that they gained new perspectives through the encounter
with their patients’ different worldviews and cultures, and that their own work gave them,
personally, a sense of meaning.
In the literature, the term “vicarious trauma” was introduced by McCann and Pearlman
(1990), labelling the profound changes in worldview that can occur in professionals when they
work with people who have experienced trauma. Similar concepts are compassion fatigue, burnout,
secondary traumatic stress, and empathic stress (Figley, 2002; Puvimanasinghe et al., 2015). The
DSM-5 explicates in the part on diagnostic criteria of PTSD that secondary traumatic exposure can
cause impairing symptoms requiring treatment (American Psychiatric Association, 2013; Hensel et
al., 2015). In line with the findings of this dissertation, professionals internationally have reported
high levels of stress and vicarious traumatisation resulting from the work with refugee patients, but
also positive impacts, such as the experience of vicarious post-traumatic growth, added meaning
and inspiration (Barrington & Shakespeare-Finch, 2013, 2014; Karageorge et al., 2017;
Puvimanasinghe et al., 2015). In a meta-analysis, Hensel et al. (2015) found that caseload (volume,
frequency and ratio) and a personal trauma history were risk factors for secondary traumatic stress,
whereas work support and social support served as protective factors against secondary traumatic
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stress.25 Interestingly, in the Brazilian studies, professionals explained that the impacts and
processes of personal change were not only caused by listening to traumatic stories, but also by
becoming aware of the struggles their refugee patients were facing in their daily lives in Brazil, and
by constantly being confronted with structural limitations and limited support themselves:
I have about seven or eight patients who have attempted suicide. I'm alone there. That has an impact.
(Psychotherapist, Boa Vista)
We do not have time to evaluate what is true, what is his reality or if he is freaking out. You don't have
that kind of time […] In the referrals with the network, it is also difficult, because you go to CAPS26 and
then CAPS will do a screening and say: ‘Ah this is not a case for us here’. You go to UBS27, and UBS
does not have psychological care, so how do we give this care when we have to take care of 102 more people?
Stuff like this…This raises extreme anxiousness in us. (Psychologist in Acolhimento, São Paulo)
Be it caused by structural limitations, work overload, or listening to traumatic stories, the

impacts on professionals of treating refugee patients render adequate support structures for staff
in MHSR vital (Barrington & Shakespeare-Finch, 2013, 2014). This will be discussed in more detail
in the section on positive and supportive aspects.
2.) The therapeutic relationship: importance and challenges
The therapeutic relationship was highlighted in all studies as key to the MHSR and
therapeutic process. It was often even considered the most important aspect of the MHSR, and as
therapeutic in and of itself. The relationship was described as providing patients with a safe space,
especially if professionals were able to offer long-term attendance and overcome the initial mistrust
of patients. For a positively experienced and functional therapeutic relationship, professionals
referred to the need of being fully present for the patients and supporting them in an authentic,
warm and friendly way. They mentioned that it was a requirement for the development of a
functioning therapeutic bond to show genuine interest in patients’ accounts, and to have an
authentic desire to work with this specific group of patients. In particular, empathy was often
stressed as a central component of the therapeutic relationship.
Meanwhile, participants in this dissertation demonstrated ambivalent perspectives on the
shape of the therapeutic relationship. There was a widely held agreement that the therapeutic
25Even though the effect sizes were small in both cases (see Hensel et al., 2015).
26 Psychosocial care centres in Brazil (Centro de Atenção Psicossocial)
27 Basic units of healthcare (Unidades Básicas de Saúde)
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relationship with refugee patients was special in the sense that it was often characterised by a certain
permeability and flexibility of boundaries. Refugee patients who were not familiar with
psychological care or psychotherapy, and who additionally were often socially isolated, tended to
see practitioners as family members or friends. Many professionals felt that relating in a way that
exceeded the classical therapist–patient bond was helpful in order to build trust and to advance in
the therapeutic process. They exceeded the classical bond, for instance, by attending events of
patients and their communities outside of the therapeutic space or by advocating on behalf of
patients.
You have to be flexible enough to recognise that these people see you as part of their lives and it would just
be incredibly hurtful to them for them to invite you to something and you to say : ‘No, I’m your therapist’.
(Professional, Schweitzer et al., 2015, p. 113; QES)
At the same time, negative consequences of this flexibility were addressed too. Psychologists
working in psychological care in Brazil sometimes felt that mixed-up relationship types were
burdensome for themselves and frequently the result of a forced closeness to patients in the
improvised physical work environment. Psychotherapists in Brazil shared their concerns about
creating a relationship of dependency and paternalizing patients if they exceeded their usually more
distant way of relating to patients, and got overly involved with patients’ needs. They also raised
the issue of considering themselves in a position of power in the relationship trying to be the
saviour to resolve every single need of patients. For some psychotherapists, a solution was setting
clear-cut relationship boundaries. Others merely showed their awareness of the dilemma without
feeling that they had a solution at hand.
Consistent with the results of this dissertation, studies have shown that establishing a
therapeutic relationship with refugee patients should be a priority yet at the same time represents a
major challenge for professionals. In the psychotherapy with general patients, the therapeutic
relationship or therapeutic alliance has consistently been found to predict better therapy outcomes
(Aveline, 2005; Barber, 2009; Fisher et al., 2016; Wampold & Imel, 2015; Zilcha-Mano, 2018). For
refugees, the therapeutic relationship has been postulated as very significant in order to experience
consistency in a context of ongoing uncertainty (Fabri, 2001; Karageorge, 2017), and to reconstruct
feelings of safety (Capaldi et al., 2016; Fabri, 2001; Karageorge, 2017; Murphy & Joseph, 2013).
Empathy, genuine interest and care, the aspects reported in the studies here, have also been found
to strengthen the therapeutic relationship in other studies on diverse groups of patients (Ackerman
& Hilsenroth, 2003; Wampold, 2015; Wampold & Imel, 2015). Similarly to this dissertation,
previous research has found that the development of a therapeutic bond tends to take longer with
refugee patients, since many barriers exist for refugees to develop trust in mental healthcare
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professionals (see paragraph on patients’ mistrust, pp. 209-210; Codrington et al., 2011; Sandhu et
al., 2013) and since the relationship is often influenced by the presence of interpreters (Miller et al.,
2005).
The studies of this dissertation pointed to another challenge: the question of boundaries in
the therapeutic relationship. The idea that therapists can or should advocate on behalf of patients,
accept that patients consider them as family member or friends, and meet them outside of the
therapeutic space in contrary to the “the cornerstone[s] of the majority of western therapeutic models and
approaches entrenched in positivist ideologies” (Patel, 2003b, p. 221), namely abstinence and neutrality
(Jordan & Seponski, 2018; Patel, 2003b; Speight, 2012). Some authors have, however, drawn
attention to the need to negotiate these commonly accepted therapeutic boundaries with general
patients (Norcross & Lambert, 2011; Zur, 2007), and with refugee patients in particular
(Karageorge et al., 2017; Watters, 2001). Sometimes, flexible, permeable boundaries and boundary
crossings that form part of a well-constructed treatment plan can actually augment the effectiveness
of the therapy (Gelso, 2014; Lazarus & Zur, 2002), as they can strengthen bonds between therapist
and patients, especially in culturally competent practice (Speight, 2012; Zur, 2004).
Nevertheless, as described by the participants in this dissertation, the flexibility and crossing
of therapeutic boundaries comes with certain risks. For instance, it might counteract the objective
of supporting the development of independence in patients (Codrington et al., 2011) and lead to
an overidentification of professionals with patients (Kronsteiner, 2017). Furthermore, defenders
of a neutral attitude of the professional in the therapeutic space postulate that healing works best
when psychological techniques and expertise only are applied (Fife & Whiting, 2007). However,
others have argued that taking a stance that is a fully neutral position is impossible in psychotherapy
(Fife & Whiting, 2007; Yamamoto, 2007).
Positive and supportive aspects of the MHSR

Furthermore, results of the studies of this thesis shed light on a variety of positive and
supportive aspects for psychotherapy and psychological care with refugee patients. The unified
aspects across studies discussed in this dissertation concern the approach to MHS, three types of
awareness in professionals, as well as the support that professionals receive themselves.
First of all, three major aspects were stressed in the studies in relation to the approach to
mental health support for refugees: flexibility and (context-)adaptability, collective work strategies
and a focus on fostering independence and emancipation in patients.
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1.) Flexible and (context-) adaptive approaches
The first aspect concerning the approach to MHSR is summarised here as a flexible and
adaptive posture and practice.
If you come from the private clinic, from the individual psychotherapy practice, it is totally different, it's
something else. So you also have to understand that it is an extended clinical work. We have several
professionals with whom we have to have contact. It is not that sort of patient who has an appointment, who
arrives, talks, bye, until next week. No. (Psychotherapist, São Paulo)
Participants perceived that it was most helpful if the approach was patient-centred, with the first
step consisting of observing and understanding patients’ needs and contexts, and consequently
adapting the therapeutic process and interventions accordingly. Patients’ needs were often
described as assuming a hierarchal form, with the first priority being basic needs, such as security
and housing. Thus, sometimes it was necessary for the professional to adapt to the needs of patients
that had the highest priority by engaging in tasks that were not classically “psychological”, such as
assisting patients with their practical problems. This frequently meant focusing more on psycho-
social than pure interindividual, psychological work, providing information, direction and
orientation for refugees in the host country, or sometimes even advocating on behalf of refugees
and engaging in political work. For such an adaptation to be possible, psychologists had to be
willing and flexible to change previous ideas of therapy and adapt their techniques, and they needed
to be open to new and unusual situations. A concentration on integrative work, rather than using
specialised techniques or rigid approaches was considered helpful, as well as the attitude of co-
constructing the therapeutic space with the patients. Adaptation was also necessary regarding the
content of the therapy – professionals highlighted that for some patients it was, for instance, very
important to focus on the here and now, instead of addressing past traumas. Meanwhile, this had
to be assessed for each patient individually and in accordance with the stability of his or her context.
For Drožđek (2007) the flexible adapation to each patient and their context is an integral
part of the mental health support for refugees:
When planning interventions, the mental health professional together with the client has to rank the priority
areas of change. In some cases, where the ‘mental engeneering’ of individual problems is the highest ranked
one, the professional is offered a space to work on the integration of fragmented traumatic experiences. This
task is the closest one to the “classically” defined professional role of the western (psycho) therapist. In other
cases, where the “social engineering” and the reparation of the damaged social tissue deserve more attention,
practical aid must be offered in combination with symptom control, aiming at stabilization of the client as a
necessary precondition for further healing. Reparation of the social tissue empowers social coherence, and
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mobilizes social support, enabling trauma victim to re-enter his/her social group. In the latter case, the
professional has to expand and redefine boundaries of his professional role. (Drožđek, 2007, p. 12)
Interest has recently increased in looking for treatments that are most effective for a specific
group of patients instead of attempting to find the best diagnosis-specific treatment (Fisher &
Boswell, 2016; Zilcha-Mano, 2018). This has resulted in what is called “personalised treatment”
(Zilcha-Mano, 2018, p. 1). Personalised treatments often involve transdiagnostic strategies (Fisher
& Boswell, 2016) and are based on the assumption that identifying fine-grained differences among
patients can lead to insights about what sort of treatment interventions are most appropriate for
which patient (Zilcha-Mano, 2018). Indeed, studies have shown that patient characteristics better
predict outcomes than any specific type of treatment intervention (Zilcha-Mano, 2018; Zuroff et
al., 2000). The present dissertation supports the view that tailoring treatments to the specific
characteristics of refugee patients is important, but that mental health professionals often need to
be even more flexible than that: they often will have to tailor their work to the contextual situation
of the refugee patients. Such “contextual work”, or what professionals in Brazil called “clínica
ampliada”, may involve working the “social engineering” mentioned in the quote by Drožđek (2007, p.
12) above – in other words, practical aid, political and psycho-social engagement.
The idea of a clínica ampliada forms part of one of the main conclusions of this dissertation
illustrated in Figure 20 – the observation that mental health support with refugee patients seems to
transcend boundaries in a threefold way. First of all, often the therapeutic relationship boundaries may
permeably be transcended, as was described in the discussion of ambivalent aspects above. The
flexible and context-adaptive approaches elaborated here, concern the second and third way of
boundary transcendence – the second way is the transcendence of space boundaries, when
professionals leave the four walls of their therapeutic practice to care for patients’ contextual needs,
or when the patients’ contexts enter the four walls of the therapeutic space. The latter happens, for
example, if patients receive bad news from their CoO, or a worrisome document from the host
country, such as a rejection letter of their claim for asylum. The third way, then, is the transcendence
of the boundaries between therapeutic schools and orientations. This is what professionals make
use of when they provide integrative treatment strategies and flexibly adapt their support to the
patients.
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Figure 20
Transcending boundaries in the mental health support with refugee patients
Similarly, to the flexible boundaries in the therapeutic relationship, contextual work constitutes a
balancing act for professionals. Working with patients’ contexts may cause an overinvolvement of
professionals, carries the risk of counteracting patients’ independence and self-efficacy (Codrington
et al., 2011; Kronsteiner, 2017) and thus, of marginalising patients even further (Jordan & Seponski,
2018) and jeopardising the mental health support (Apostolidou, 2015). Expanded clinical practice
(clínica ampliada) may also dismiss valuable specialised and technical therapeutic knowledge
(Marsillac et al., 2018; Yamamoto, 2007). On the other hand, a treatment which does not involve
contextual work, might imply a too rigid perspective that focuses, in some instances, excessively
on technical and biomedical aspects of mental health and mental health support. It risks ignoring
the multidimensionality and complexity of mental health problems, which are inserted in a socio-
political context (Marsillac et al., 2018; Yamamoto, 2007). Professionals are therefore challenged
to find a balance between an overengagement and an ignorance of the socio-political context of
patients and its impact on their mental health.
A particular question in regard to the adaptation of approaches to patients and to expanded
clinical/contextual work concerns the aspect of advocacy. Some authors have written about the
benefits of taking on a political stance in mental healthcare and advocating on behalf of clients
(Karageorge et al., 2017; Puvimanasinghe et al., 2015; Rousseau, 2018). Advocacy can have a dual
advantage: firstly, it may help refugee patients directly with practical matters and better their living
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situation in the post-migration context. Secondly, it may also indirectly help by building trust in
refugee patients towards their mental health professionals and facilitate bonding (Karageorge et al.,
2017; Puvimanasinghe et al., 2015; Watters, 2001). Advocating on behalf of refugee patients may
be seen as necessary socio-political engagement of psychologists and as an expansion of the
therapist’s professional role (Drožđek, 2007). For some authors, extending the clinical work to
include advocacy on behalf of refugees forms part of the ethical duties of mental health
professionals (Zion, 2013). It may particularly turn into a necessity when patients do not place
much importance on the MHSR, since their basic needs remain unmet (Apostolidou, 2015;
Codrington et al., 2011). For others (e.g. Al-Roubaiy et al., 2017), it entirely depends on the
professionals’ personal views and policy as to whether or not advocacy should be employed. The
participants in the studies of this dissertation were largely proponents of advocacy, but also argued
for cautiousness so that professionals would not become overwhelmed. Meanwhile, they
demonstated certainty, as others have (e.g. Fife & Whiting, 2007; Rousseau et al., 2008; Yamamoto,
2012), that a neutral attitude in the therapeutic space is not possible, but
In fact, because of the benefits and privileges that researchers and clinicians enjoy within these [our society’s]
institutions and because systematic denunciation of all forms of institutional racism and injustice is virtually
impossible for a person remaining within the system, a "pure" position without any complicity is an illusion.
(Rousseau & Kirmayer, 2010, pp. 65-66)
Pracitical guidelines of how professionals may best advocate on behalf of their patients and
intervene in their context have been developed, such as the Advocacy Competencies Framework
(Toporek et al., 2009). This framework addresses, for example, three levels: 1) the patient level
(empowerment and advocacy); 2) the community level (collaboration with organisations); and 3)
the public arena (influencing public policy, informing the public about discrimination and
problems; Toporek et al., 2009).
2.) Collective work strategies
Collective work strategies were promoted across the studies of this dissertation as a way
to cope with the balancing acts of flexible relationship boundaries, contextual work and adaptive
approaches. These strategies included group therapy, co-therapy, teamwork and the cooperation
with networks and the community. Even though problems, such as conflicts in teamwork, were
mentioned, professionals felt that working alone and isolated in the MHS with refugee patients was
too challenging.
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Well my biggest support is the psychology team itself. We are quite... We have four psychologists and we
have a very good relationship, a very great bond of trust. So we usually discuss the difficulties. We share
strategies, we strengthen our relationships among us and with others, for example with teachers, with
coordinations, with the university. So for me it is very important to feel this security that exists in the team
itself. Sometimes a person has demands that we cannot take on. And then we manage to pass on to the
other and the other will embrace it. We do this very significant support process and it gives an important
feeling of professional security. (Psychologist in Acolhimento, Foz do Iguaçu)
Psychotherapists also stressed co-therapy as a useful approach to integrating multiple perspectives

in the therapeutic space. In Brazil, co-therapy was also mentioned as a means to design a less
threatening situation for refugees from cultures that not commonly employ one-to-one settings.
Professionals in Brazil were also advocates of a more social perspective in the MHSR in general.
They highlighted that, since patients’ contextual situation had to be taken into account and since,
often, the best way of improving patients’ mental health was actually by creating inclusion, access
and satisfying basic needs, psychologists were best advised to work in networks. Such
interdisciplinary networks, consisting of lawyers, psychiatrists, social workers and other
professionals to whom patients could be transferred, allowed the addressing of patients’ complex
needs without the risk of single professionals becoming overwhelmed.
The psychology of migration needs to work beyond the office in order to create these support networks and
create these links outside so that refugees can continue life (Psychologist in Acolhimento, Curitiba)
Look, I think the resource I'm looking for is first to create social networks, get to know the places and the
people. Creating networks with other professionals, other people. Since I see that we don't have an answer
from the state, or we do, but it could be more, one of the resources is to seek the solutions within the people
and professsionals who are here. (Psychologist in Acolhimento, Pacaraima)
The focus on a social perspective in mental healthcare and collectivity that became apparent
in the studies situated in Brazil may not be surprising considering the fact that community therapy
(terapia comunitária) was founded in Brazil (Barreto & Grandesso, 2010) and the Brazilian
healthcare system concentrates on social and community issues (Paim et al., 2011). However, the
QES also found that professionals experienced collectivity-based strategies, such as group therapy
and interdisciplinary networks, as helpful. The usefulness of collectivity-based strategies in therapy
with refugees has been stressed by others (Barrington & Shakespeare-Finch, 2013) regarding
teamwork, co-therapy (Pocreau & Martins-Borges, 2013), networks, group therapy (Drožđek, 2007;
Fischman & Ross, 1990; Kevers et al., 2016) and community interventions (Goodkind et al., 2014;
Moleiro & Goncalves, 2010; Somasundaram & Sivayokan, 2013; Westoby, 2008). For
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psychologists, collective settings such as co-therapy, which involves two or more therapists
(Pocreau & Martins-Borges, 2013), as well as the insertion of professionals into teams and
interdisciplinary networks, may be a means to reduce the burden on individual professionals and
consequently improve their ability to provide adequate MHSR (Mewes et al., 2016). For refugee
patients, group therapy and community-based practices may, particularly in the realm of trauma
therapy, serve to construct a space in which people can connect to people in similar situations,
share and talk about a plurality of strategies to address social ruptures, self-estrangement, and to
restructure memories linked to the trauma (Kevers et al., 2016; Kirmayer, 2015). Resources that
foster well-being not only lie within individuals, but within the communities in which people live,
too (Prilleltensky, 2005). Meanwhile, it has also been emphasised that is important to be aware of
the existence of, and provide the space for a multiplicity of voices (Rousseau, et al., 2005) and thus
also allow for individual attendance of refugee patients (Kevers et al., 2016).
3.) Supporting independence, autonomy and empowerment
The third aspect concerning the approach to MHS that became apparent in all studies is
summarised here as “supporting patients’ independence, autonomy and emancipation”.
All participants emphasised the importance of establishing independence and confidence in their clients to
enable them to overcome initial resettlement difficulties and successfully navigate the Australian system.
They described striving to enhance clients’ independence and confidence, and the personal satisfaction they
experienced when they observed clients gradually gaining in independence and confidence. (Puvimanasinghe et
al., 2015, p. 10; QES)
Professionals agreed, that there was a high risk of paternalizing and dependency
relationships with refugee patients, due to the specific conditions and post-migration situation of
refugees and their complex problems, which often rendered them helpless. These dependency
relationships were characterised by the desire and tendency in professionals to solve all problems
for their patients. In the long run, this tendency was described as leading to problems such as
burnout in professionals and as hindering refugees from developing sustainable solutions and
acquiring the necessary skills in order to navigate their new and challenging context. Participants
in all studies emphasised, that professionals should try instead to support their refugee patients’
emancipation in the new environment. In this regard, a focus on strengths was perceived as helpful,
as well as a high degree of transparency, psychoeducation and the work with groups. As described
in the previously, groups were regarded as important for the purpose of creating networks of
support among refugees, and helping them connect to people in similar situations. In order to
address patients’ independence, professionals furthermore highlighted the importance of
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practitioners recognising their patients’ suffering, as well as acting with respect towards refugee
patients and their understandings of mental well-being, their knowledge and their own solutions.
In the literature on psychotherapy research, psychoeducation and transparency have been
described as general principles for psychotherapeutic work (Wampold & Imel, 2015). In cross-
cultural therapy settings, these two aspects have been considered particularly essential to deal with
language and cultural differences (Asnaani & Hofmann, 2012; Rasoal et al., 2011). For refugees,
who often face a lack of transparency and information in host countries (Davidson et al., 2008; De
Anstiss et al., 2009; Sandhu et al., 2013), psychoeducation and transparency in the therapeutic space
might be even more important and necessary to build trust and to act against disempowerment and
stigma (Murray et al., 2010; Turner, 1995). They might also foster refugee patients’ feelings of being
actively involved in the therapeutic process. Enabling patients to play an active part in the mental
health support offers possibilities for empowerment and the feeling of being recognised (Bala &
Kramer, 2010). A focus on strengths, self-empowerment and the promotion of self-efficacy have
been stresssed by others as useful in the MHSR (Guregård & Seikkula, 2014; Sveaass & Reichelt,
2001; Yohani, 2010), particularly, as such a focus can counteract the creation of victim–saviour
dyads (Papadopoulos, 2001). For instance, Goodkind et al. (2014) showed that through learning
how to navigate in the host country, its systems and environment in a community-based
intervention, refugee patients experienced an augmented feeling of empowerment and confidence.
4.) Three types of awareness in professionals
There is a loss involved in never facing the challenge of having to observe and adapt to (or reject) the culture
and mores of a majority…While none of us is responsible for the narrowness of our childhoods, we all have
a responsibility to develop our own ‘polyphony’ to embed cross-cultural thinking in our everyday lives…“
(Daniel, 2012, p. 104-105)
Three elements that referred to characteristics or competencies of professionals

were consistently stressed as supportive for the MHSR (see Figure 21). Firstly, participants
highlighted the need for practitioners’ cultural awareness, cultural sensitivity or cultural humility.
Many participants felt the need to include perspectives that pay attention to intercultural aspects of
psychology in university curricula as a means to raise awareness about cultural differences and to
counteract ethnocentrism among psychologists. They described how many psychologists struggled
with their own ethnocentrism in the therapeutic space, for instance with regard to assumptions
about patients’ CoOs, unreflected ideas of “normality” and “health”, as well as regarding appropriate
styles of communication and relationships. Overcoming this ethnocentrism was seen as a challenge,
but possible through strategies such as cultural decentring and cultural humility, which were
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explicated as becoming aware of one’s culture, decentring from one’s own values and questioning
one’s knowledge.
Figure 21
Three types of professional awareness
Rather than psychologists having “solid knowledge” about other cultural contexts,
participants in all studies stressed the importance of the professionals remaining open-minded,
curious, and willing to learn from patients. A non-judgemental, not-knowing posture and displaying
an attitude of respect for otherness was seen as key, as well as professionals being open to listen to
and learn about patients’ world constructions, proper cultural ways of being and healing, about
their habits and customs. Psychologists also had to be aware of the fact, that refugees in host
countries had left aspects of their culture in the CoO, were exposed to a new culture in host
countries and frequently experienced to some extent cultural shocks. Additionally, participants felt
that it was easier to connect to patients when psychologists showed interest in patients’ cultures
and attempted to build a bridge to the CoOs of patients, for instance by asking questions about the
country, language and customs, by speaking patients’ language or by using maps in interaction with
patients to understand the geography of patients’ background. Professionals perceived that a
cultural mediator, who not only translated the language in the therapeutic setting but also provided
background knowledge about patients’ CoOs could be very useful, but few participants in the
Brazilian studies had access to such a support.
Many authors have stated that it is important for psychologists who work with immigrants
and refugees to have, on the one hand, an awareness of the aspects that are involved in a migration
process, such as leaving behind elements of one’s culture and being confronted with new cultural
scripts or cultural frames of reference (Bhugra, 2004; Bhugra & Minas, 2007; Karageorge et al.,
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2017; Kizilhan, 2018; Kronsteiner, 2003; Martins-Borges & Pocreau, 2009b). Cultural adaption can
be considered a cause of substantial distress in immigrants (Knipscheer & Kleber, 2006; Martins-
Borges, 2013, 2017). For professionals working in the mental healthcare of people who have
migrated, a knowledge of these factors and processes seems necessary to be better able to
understand and accommodate patients’ needs. On the other hand, professionals need a capacity to
deal with and accommodate cultural differences in the therapeutic space. Fuertes et al. (2006)
describe how a neglection of the need for cultural competency may potentially harm the therapeutic
relationship and working alliance in the therapy, which in consequence can adversely affect the
process and outcome of the mental health support (Fuertes et al., 2006). Various concepts have
been developed in the literature to describe an understanding in professionals of what it means to
leave one’s culture(s) of origin, and an accommodation for cultural differences in the therapeutic
space. These concepts include “ethnic matching”, “cultural competence”, “cultural awareness”, “cultural
sensitivity”, “cultural humility” and “cultural safety”. Such concepts have recently become of growing
interest in an attempt to address the challenges related to working in increasingly multicultural
mental health support settings (Cénat, 2020; Kirmayer, 2012b). Ethnic matching refers to the idea
that professionals and patients should be from the same cultural or ethnical background (Cabral &
Smith, 2011; Karlsson, 2005; Kirmayer, 2012b). Apart from often being a resource problem (it is
rare to find professionals from all sorts of cultural backgrounds in a single place), the concept is
also associated with issues of discrimination (for a discussion see e.g. Kirmayer, 2012b). Many of
the other earlier concepts to accommodate cultural differences in the therapeutic space are focused
on knowledge-based understanding – that is the idea that professionals should have specific
knowledge regarding the countries and cultures of origin of their patients. These concepts come
with the problem that they risk essentialising cultures and stereotyping patients. By learning “solid
facts” about specific cultures, habits, and traditions, professionals may develop prejudiced attitudes
and lose a nuanced view on patients and their cultures of origin (Gozdziak, 2004; Hook et al.,
2013). Essentialisation and culturalisation of patients and their origins then become barriers to
therapeutic successes (Heise et al., 2001; Zultner, 2014). For these reasons, participants in the QES,
as well as the psychologists in psychological care and psychotherapists in Brazil, stressed instead a
kind of cultural awareness or sensibility that involved
1.) an awareness of their own cultural identity,
2.) a humility and non-judgmental attitude to constantly learn from the other,
3.) a questioning of presumptions.
Thus, the concepts of “cultural humility” (Hook et al., 2013; Kirmayer, 2012a, 2012b; Tervalon &
Murray-Garcia, 1998), “cultural reflexivity” (Aronowitz et al., 2015), or “cultural decentring” (Guzder,
2014) may be best suited to describe the approach the participants in this dissertation found helpful
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to address cultural differences in the MHSR. Common to these concepts is that they involve an
attitude of curiosity and humility in professionals, an awareness of the limits of one’s own
knowledge, and an openness to constantly examine own cultural presumptions (Bracken et al.,
1997; Flaskas, 2012). This reflexivity is described by Paolo Bertrando (2012, p. 122) in the following
words:
She observes emotional states in her patients, and experiences emotional states in herself. If she imagines
that she immediately understands the meaning of such emotional exchanges, she is taking for granted that
she and her patients are sharing exactly the same ethos, an assumption that is questionable even if they
actually share the same cultural background […]
Unreflected and taken-for-granted understandings in mental health professionals will

influence their practice and methods (Guzder, 2014). Self- and cultural reflexivity poses the
challenge for professionals to keep in mind that they themselves are part of a cultural frame of
reference (Martins-Borges, 2013).
Just as we are unconscious of many of our motivations and patterns of thought and behaviour until they are
reflected back to us by others, so too we are unconscious of our cultural background knowledge and
assumptions.
(Kirmayer et al., 2015, p. 2)
This may be new, in particular to professionals who have lived all their life as part of the majority
population in a country (Krause, 2012). While the dynamics of cultural contexts affect
psychological processes to a large extent, the dominant paradigms in the training of mental
healthcare professionals, as well as in the approaches to assessment and treatment still tend to
minimise cultural issues (Guzder, 2014). This criticism underscores the importance of including
cultural psychology in the education and training of mental healthcare professionals, which will be
discussed in relation to the practical implications in the final chapter of this thesis.
Cultural awareness is closely linked to a second type of awareness: Self-awareness.
Participants in this dissertation called for an ongoing process of auto-inspection and reflection in
psychologists so as to become aware of their own values, ideas and reactions that would eventually
influence the therapeutic relationship and process with patients. On the one hand, this self-
awareness related to aspects of cultural differences discussed in the previous paragraph:
psychologists pointed especially to the need of being conscious about the fact that their own
cultural background, not only that of their patients, is brought into the therapeutic space. In order
to practise the previously described cultural humility and cultural decentring, but also theoretical
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decentring of pre-established theoretical assumptions, a self-awareness was key. Furthermore, self-

awareness was perceived as central, with an eye toward one’s own mental health. Practising self-
awareness meant to professionals becoming conscious of personal tendencies, such as attempting
to resolve all of refugee patients’ complex problems, of sensitive topics and emotional reactions,
for instance to a specific type of story.
A second tip I would give you is that you always need to recognise that you are getting anxious and
anguished. Because if you don't know you respond from the anguish, then everyone is wrecked in the same
boat of anguish together. This work brings anguish all the time. So even if sometimes there is no way... we
answer from the anguish, but at least we know that we have answered from the anguish. Then we review it
and see how we can do it differently. (Psychotherapist, Curitiba)
The attempt to solve all of patients’ problems was frequently described as an urge of professionals
to feel or remain in a “position of power”. On the one hand, this was motivated by the wish to
demonstrate to patients one’s capacity to find solutions to their needs. Professionals reported that
there was a risk of wanting to be perceived as the “saviour” who could help patients with anything.
The problem of saviour-victim dyads has been described in the literature previously
(Papadopoulos, 2001). On the other hand, the urge for the “position of power” was explained as a
type of compensation strategy to override the helplessness and the impotence professionals felt
when confronted with the complexity of the refugee situation. Psychologists shared that there was
a tendency in their work to attempt lessening one’s impotence by taking action oneself. Research
has shown that lack of power is a key element behind negative stress (Kizilhan, 2018; McCubbin,
2009; Ogden, 2012) which is why professionals who work with refugees might be prone to take
action in order to regain a feeling of power and protect themselves from negative impacts of the
work on their mental health.
There is a vast literature on self-awareness in mental health professionals and its importance
for the therapeutic process, particularly in cross-cultural therapy settings (e.g. Burnham, 2012;
Gelso, 2014; Kirmayer, 2012a; Krause, 2009, 2012; Roysircar, 2004). The professional’s own self
forms a structural part of the therapeutic encounter, and will both influence and be influenced by
it (Baker, 1999). As found in this dissertation, there are three major points in the literature related
to the need for self-awareness in professionals:
1.) it functions as a foundation for cultural humility and decentring,
2.) it serves the therapeutic relationship and working alliance,
3.) it is a central pillar for the self-care of mental health professionals.
The first point concerns what has been called a “multicultural conscience” or “consciência multicultural”
(Moleiro & Gonçalves, 2010, p. 507). This conscience consists of the self-knowledge or self-
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awareness of the mental health professional about his or her own (cultural) values and attitudes,
about prejudice and assumptions he or she holds about the “other”, as well as of the awareness of
the fact that these aspects can influence the interaction with patients in the therapeutic space (Katz
& Alegría, 2009; Moleiro & Gonçalves, 2010; Rousseau et al., 2008). An in-depth self-examination
is necessary for mental health professionals, particularly for those in multicultural settings, to raise
their self-awareness about their own background regarding factors such as their culture, economic
and social class, race and gender (Baker, 1999; Burnham, 2012). Self-reflection is also necessary to
avoid microaggressions and become aware of own racist attitudes in multicultural mental health
support (Cénat, 2020; Rousseau et al., 2008). Research has shown that healthcare professionals can
hold stereotypical images and preconceptions about patients, which are based on impoverished
ideas of a specific group membership (Baker, 1999; Katz & Alegría, 2009). The second point relates
to the fact, that mental health professionals seem to be better able to establish functioning and
trusting therapeutic relationships when they use introspection to gain awareness about their
(cultural) values and assumptions, as well as about their reactions to cultural differences with
patients (Baker, 1999; Roysircar, 2004). In order to avoid falling into saviour-victim-dyads
(Papadopoulos, 2001), and to be able to transparently and clearly communicate the limits of their
professional role and establish (permeable) boundaries in a therapeutic relationship, mental health
professionals need self-awareness (Gelso, 2014). Thirdly, self-awareness and reflexivity form a
central component of self-care for mental healthcare providers (Barrington & Shakespeare-Finch,
2014). Professionals have to monitor their own feelings and mental health, be aware of their role
and limitations, and implement strategies to promote their own well-being. This is highly important
to counteract the development of compassion fatigue or vicarious trauma, especially for those who
work with patients who have experienced trauma (Apostolidou, 2016b; Barrington & Shakespeare-
Finch, 2014; Figley, 2002).
As a third type of awareness, professionals in this dissertation stressed the need for
contextual and political awareness in practitioners. In the QES, patients especially commented
critically on a lack of mindfulness of the refugee situations in therapists. Professionals in all studies
agreed that numerous aspects of patients’ suffering related to their past and present socio-political
context, such as the experience of discrimination and racism, social isolation, housing and
economic difficulties, unemployment, insecure asylum status, future uncertainties, as well as the
past and current situation in patients’ CoO. Professionals felt that, therefore, practitioners needed
to be aware of these factors and underscored the importance of an understanding in mental health
professionals that many of refugee patients’ problems were not purely individual in nature, but had
a crucial social and political dimension. Context, thus, had to become a fundamental feature of the
therapeutic process. A contextual awareness in professionals was perceived as being essential to
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communicate a knowledge and recognition of patients’ suffering in order to build a trustful

therapeutic relationship. The socio-political dimension of patients’ suffering was named as one of
the main reasons for the adaptation of the therapeutic process to patients’ needs, for valorising
social and community work approaches and using interdisciplinary networks. Furthermore, the
contextual and political awareness was described as helping practitioners to be prepared for and
not be overwhelmed by the challenges refugee patients had to face in host countries.
It is a therapeutic service. Therapeutic logically, obviously. Like this we present our work, but it is also
obvious that this broader psychosocial issue enters, because they [the refugee patients] have a whole
vulnerability not only a psychic one, but also an economic and legal one. (Psychotherapist, São Paulo)
Participants typically conveyed the importance of practitioners being mindful of their experiences as refugees,
as Christina said: ‘You can’t take someone like refugee and someone Australian ... as counsellor, just say,
‘‘this is gonna help you’’— no. There’s some Australian they just grow up here – they have everything, they
doesn’t see fighting, they doesn’t sleep no eating ... [refugees] eat, like a brick, you know, you eat like
something because you need like your stomach to come to feel like you have something to eat. They’re
suffering ... fighting is still there ... yesterday there are people dying there.’ (Refugee Patient; Valibhoy et al.,
2017, p. 10; QES)
Contextual and political awareness has become known in the literature as “structural
competency” (Metzl & Hansen, 2014) and refers to a recognition of the manner in which structural,
social and economic forces impact the (mental) health of individuals. For example, many refugees
do not have a “safe home” to return to after a session, but continue in a situation of high instability.
Therefore, the way in which psychologists can treat refugee patients cannot be the same as treating
a person in a stable context; for instance, instability frequently leads to methods of trauma exposure
being risky and potentially causing more harm than good (Brunnet et al., 2018; Carrasco García,
2010; Davidson et al., 2008; Knobloch, 2015; Momartin et al., 2006). Psychotherapists who do not
carry an awareness of the context of refugee patients may, thus, end up using inappropriate
intervention strategies. Furthermore, refugee patients often expect that professionals take their
context and the socio-political aspects of their problems in mental healthcare settings into account
(Bala & Kramer, 2010; Karageorge et al., 2017). A missing contextual awareness may thus
disappoint patients and negatively affect the therapeutic relationship. Summerfield (1999) is one of
the most famous authors to criticise a general lack of socio-political awareness in the mental
healthcare profession and the profession’s tendency to medicalise and individualise structural
problems. Some authors have proposed that more than contextual and political awareness, political
action is a relevant task for mental health professionals, since these professionals witness and gain
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specialised knowledge of the structural problems affecting patients (Jordan & Seponski, 2018;
Rousseau, 2018; Waldegrave, 2009). This argument relates to the previously discussed topic of
context-adaptive approaches and advocacy in the MHSR. Psychotherapy researchers and
professionals internationally may hold diverse and diverging views on the limits and boundaries of
a psychologist’s role and tasks. Independent of the multiple viewpoints, it is important to recognise,
however, that the professional is a subject who holds proper socio-political beliefs that will
permeate their clinical work. As is the case with cultural assumptions, the psychologist has to
become conscious of political worldviews. Otherwise they risk to disenfranchising or marginalising
their refugee patients further (Avissar, 2016).
5.) The therapist’s therapist
[…] be able to rely on the network. The whole care network, not only public services. Be it the mental
health network, but an affective network, a network of other psychologists who can think about the case,
discuss, rely a lot on supervision as a space for reflection. (Psychologist in Acolhimento, Florianópolis)
The aspects of MHSR that were discussed in the previous paragraphs can be seen to
interdepend greatly on the support structures available to professionals themselves. Participants in
all studies stressed the need for supervision, intervision, and interdisciplinary networks of
professionals as well as proper psychotherapy for professionals. The necessity to improve the
access to such support structures for professionals who attend refugee patients was underlined
with two principal arguments. Firstly, participants perceived that professionals needed a space for
auto-reflection and for developing their self-, contextual- and cultural awareness. Supervisors could
identify unconscious values and reactive tendencies of professionals and challenge their pre-
established and taken-for-granted assumptions. Secondly, support structures could provide
personal relief to professionals, diminish the feeling of being alone with their work, encourage
them, provide moral support and train their frustration tolerance. Nevertheless, in all studies
professionals also highlighted that support structures were rarely in place. This was seen to augment
the risk of negative impacts of the work in psychologists.
[…] but this also involves the work of supervision, and the treatment of each one as well. Because it is
theoretically very easy for us to talk about dealing with the cultural difference and to make this radical shift
to attend to the culture of the other with the possibility of healing. But we do this by talking and the
language is subject to intents. So sometimes it is such a challenge. To understand some things. For example,
the role of gender. To accept some things. To accept some things that patients brought. Trying to be more
interested in some things because in a very ethnocentric position, we interpreted very quickly. Even if the
patient did not speak. I think there is a basis that is very delicate which we also studied in the supervision.
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That's why it's a condition to have supervision. In supervision we discuss and understand some things that
were confusing or clear and certain to us and not so certain. We also learn to create doubt in order to be able
to install doubt in others. We also have unreflected things, we also have certainties that are not so certain,
they are right and certain for us in our environment, but only there. (Psychotherapist, Florianópolis)
The scientific literature shows unanimity regarding the necessity for appropriate support
structures for mental healthcare professionals in general, and particularly for those who work with
refugee patients (Apostolidou, 2016b; Barrington & Shakespeare-Finch, 2013, 2014;
Puvimanasinghe et al., 2015). However, especially regarding the mental healthcare for refugees
funding and opportunity for these support structures are often absent:
And I wish that there was a supervision, and not only a supervision, but a meeting of all areas and
diciplines for us to talk together about that person. I know that this would also be important for the
professionals themselves. I think that the psychologist ends up seeing himself, in this context of our reality
here, we end up seeing ourselves very alone, trying to juggle with five beanbags and not letting any of them
fall. (Psychotherapist, Curitiba)
Without the possibility for reflection with other professionals, the development of self-awareness,
cultural and contextual awareness in psychologists is hardly possible. This increases the risk of
privileging the unreflected and unconscious ideas and understandings of professionals, such as
concepts of health and illness, before those of patients (Krause, 2009). Furthermore, mental
healthcare professionals, especially those that work in emergency-like settings, as in the case in the
Brazilian state of Roraima at the moment, run a risk of developing mental illnesses themselves, if
they do not receive appropriate support (Barrington & Shakespeare-Finch, 2013, 2014; Hensel et
al., 2015).
Interlinks with the findings on refugee patients’ psychological suffering

So far, I have discussed the specificities and commonalities of the results, particularly
among the QES and the two studies concerning the mental health support for refugee patients in
Brazil. These findings about the experience of MHSR are visibly linked to psychologists’
perceptions of the suffering of their refugee patients. Many of these links have been mentioned in
the text above. For the sake of completeness, I will highlight some of the interconnections in what
follows.
First of all, the strong emphasis on the post-migration situation as hindering for the
therapeutic process, as well as the need for context-adaptive approaches and political and
contextual awareness in professionals, reflect that participants perceived refugees’ suffering as socio-
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political suffering and frequently saw patients’ symptoms as normal reactions to their past and present
experiences. The criticisms of Western psychiatric diagnostic manuals present among professionals
in Brazil partly pertained to this aspect: as professionals often perceived refugee patients’ suffering
as socio-politically caused, they did not find it adequate to use diagnostic categories, nor to use
approaches that would individualise or medicalise the problems of patients. Instead, they
highlighted the adaptation of therapeutic approaches to patients’ needs and the transcendence of
“classical” therapeutic work boundaries, such as through engaging in social work or advocacy. Also,
the fact that many refugee patients were perceived to suffer from experiences of xenophobia,
racism and discrimination relates to the finding that psychologists called for an awareness about
these contextual issues in professionals in order to provide adequate support for their patients.
Similarly connected to contextual awareness is the result that psychologists perceived that the flight
was a life rupture for patients, and that the situation in patients’ countries of origins continued to
heavily affect their psychological well-being. Furthermore, the necessity for cultural awareness
stressed by participants as a further characteristic in professionals, links in part to the result that
processes of cultural adaptation and cultural shock were regarded as causing suffering in patients.
Secondly, psychologists described social isolation in patients as a substantial part of their
suffering. This relates to the challenge of establishing a balanced therapeutic relationship with
refugee patients – a relationship in which the psychologist neither feels overwhelmed, as if she or
he is the only bond for the patients and alone responsible for their well-being, nor keeps too rigid
boundaries, that hinder the development of trust. Social isolation as suffering also matches the
finding that the approach should focus on creating networks among patients in group therapy, and
on supporting patients’ independence, autonomy and empowerment.
Finally, the traumatic experiences that were described as causing psychological suffering in
patients connect to the work impacts on professionals, as well as to the call for better support
structures for professional and collective work strategies.
232
Chapter 9
Limitations, Implications and an Overall
Conclusion
Section III | Chapter 9 Conclusion
Limitations of this Dissertation and Future Research

While the specific limitations to each of the studies have been discussed in the respective
chapters, there are several general limitations to the findings of this dissertation, which will be
addressed in the following section and linked to possibilities for future research.
Firstly, the results of this dissertation are limited by the fact that the second section, the
fieldwork in Brazil, is based on professional psychologists’ perspectives only. The decision to
include only psychologists as participants was based on issues of practicality: including more than
the 32 conducted interviews, and analysing interviews of another participant group separately,
would have exceeded the scope of this dissertation and its time and financial resources.
Furthermore, the access to refugee patients is a challenging and an ethically sensitive topic and
might require a different research approach altogether (Ahearn, 2000a). Meanwhile, research in the
area of mental health in general could benefit greatly from including the perspectives and
experiences of patients (Donald & Carey, 2017; Levitt et al., 2016). In the area of qualitative health
research, this is already quite common (e.g. Booth, 2016). Psychotherapy research, however, is still
very much focused on quantitative evidence-based practice research (Donald & Carey, 2017; Hall,
2001; Moleiro, 2010). Few studies have been conducted that take in depth patients’ perspectives
into consideration by means of qualitative methods, as for example by using patients’ feedback
(Rober et al., 2020). Mental health support for refugees in particular, could advance by looking at
refugees’ evaluations and experiences of this support. Concerning the present dissertations’
research questions, refugees’ perspectives might provide insights into further supportive and
hindering elements in the therapeutic process, including the experience of potential discrimination
and microaggressions through professionals (Constantine, 2007; Owen et al., 2011). It might also
provide the possibility to critically evaluate the findings of this dissertation by comparing them with
patients’ perspectives. For instance, it would be interesting to see whether patients themselves find
group settings as helpful as the professionals in this dissertation did. The comparison between
professionals’ and patients’ perspectives which comprised the qualitative evidence synthesis in
Section I of the dissertation, just showed slight differences in their experiences – the impacts of
the work on professionals and the need for support structures for professionals were shared by
psychologists only. However, this result may also be due to the need for converging findings of
primary studies in the analytical procedure, as discussed in Chapter 3, which might have led to a
loss of nuances in the accounts of participants. Meanwhile, research aiming to integrate patients’
perspectives may best be advised to use participatory action research designs and to partner up
with communities (Christopher, 2014; Ruiz-Casares, 2014). Particularly in the context of working
on sensitive topics with vulnerable or marginalised parts of the population, such designs in which
234
participants are integrated as active contributors and co-investigators to the outcomes have been
considered useful (e.g. Moleiro & Goncalves, 2010; Ruiz-Casares, 2014). An example here is the
doctoral thesis of Sofie de Smet (2019), which explored different modes of trauma narration
regarding experiences of collective violence and forced displacement among Syrian refugees in an
applied theatre setting. Apart from generating research findings that help unheard voices to be
heard, participatory action research can serve as a means for empowerment and to build networks
among participating individuals (Ahearn, 2000a; Christopher, 2014; Syed et al., 2018).
A second limitation of this dissertation’s findings concerns the use of a single method of
research, since only semi-structured interviews were employed in Section II of the dissertation
(Whitley, 2012). A greater focus on triangulation, that is the use of several methods to answer the
same research question, could have increased the validity and trustworthiness of the findings
(Whitley & Crawford, 2005), but again would have required more financial and timely resources
than were available for this project. Moreover, in the dissertation as a whole, triangulation or means
of data “crystallisation” were in place to some extent, since multiple viewpoints were integrated, such
as by including multiple sources of data (a synthesis of qualitative studies and primary interview
data), and discussions with other researchers on coding schemes, analysis and findings (Tracy, 2010,
p. 843). Interviews with experts, as conducted in this dissertation, were also an adequate choice in
order to gain professional insights, abstract and technical knowledge (Helfferich, 2005; Meuser &
Nagel, 2002, 2009). Whilst the present research would certainly have benefited from making use of
more sources of data, the research design used here can be considered a contribution to a greater
methodological pluralism in the field of psychotherapy research in general, since this field mostly
consists of quantitative evidence-based practice research (Donald & Carey, 2017; Hall, 2001;
McLeod, 2011; Moleiro, 2010). In particular, in cultural psychology there have been calls to move
away from purely “traditional” quantitative methods and laboratory experiments (Christopher,
2014).
Thirdly, in this dissertation no attention was paid to patient characteristics, such as their
status of asylum, their country of origin, gender, age, native languages or detailed flight experiences.
While the focus of Section II of the dissertation was the experiences of professionals, I
acknowledge that these experiences may have been profoundly affected by such patients’
characteristics. For instance, the concerns around status insecurity in asylum-seekers and their
related fear of deportation has been described to be highly influential for their mental health
(Davidson et al., 2008; Laban et al., 2008; Momartin et al., 2006) and will consequentially matter
for the therapeutic work. Gender has also been described, particularly by research in cultural
anthropology, as an important factor to consider in the experiences of collective trauma and
violence (Abel & Richters, 2009; Tankink & Richters, 2007) and in the therapeutic relationship
235
(Logue, 2012). Similarly, the country of origin of patients may influence professionals’ experience
of the therapeutic process, relationship, as well as of helpful and hindering factors, due to issues of
language differences and of cultural closeness or distance (Kirmayer et al., 2011). While in Section
I of the dissertation records were kept about patients’ CoOs (see Chapter 2, Table 2 on page 65)
and in Section II psychologists were asked to name patients’ characteristics, such as their CoOs
(see Chapter 5, Table 6 on page 129), there was no analysis of the impacts of patients’ CoOs or any
of the other described characteristics on how professionals experienced the MHSR. In the Brazilian
studies, professionals did mention that differences in working with people from diverging countries
of origin mostly related to structural issues, such as different asylum rights for diverse nationalities,
or specific traumatic stories in certain CoOs, such as the war experiences in Syria. Meanwhile, the
choice of not analysing the impacts of patients’ CoOs in more detail was taken with intent. In the
scientific literature, there have been attempts to conduct research and develop therapy guidelines
for specific groups of patients, for instance in Germany with patients from the former Yugoslavia
(Joksimovic, 2009) or with Turkish migrants (Hartkamp & Erim, 2009). While there might be utility
for these and similar guidelines, such as providing a sense of security for professionals who are
inexperienced in working with patients who have a different cultural background than themselves,
there is some risk involved in such approaches. A focus on a group of patients from a single country
may lead to a homogenisation, culturalisation and essentialisation of this group in therapy. Looking
at Syrian patients, for instance, there is an enormous ethno-religious complexity in the diasporic
communities, involving Arabs, Kurds, Druze, Sunni, Ismaili, Armenians, Turkomen, Aramaean,
Assyrian and others, which is permanently evolving (De Smet, 2019). Despite the fact, that many
experiences of Syrians, such as the witnessing of a war, may be shared, it is difficult to believe that
the experience of MHSR with and for each Syrian refugee patient is the same. First, culture is difficult
to set as a synonym with nation. Particularly if we conceive culture as the social world we are
embedded in from birth, as dynamic, adaptive and ever-changing (Eastmond, 2000; Kirmayer &
Gone, 2010), a pure nation-focus does not do justice to its complexity. Culture incorporates more
facets than nation, such as social class, ethnic community, linguistic community and religion.
Nation, on the other hand, is made up by cultural, and also by non-cultural factors. Thus, when
looking at cultural differences in the therapeutic space, it does not suffice to search for these
differences across particular nationalities. In contrast, focusing on the MHSR experience with
refugees from a particular nation may carry the danger of favouring a tendency that pays attention
exclusively to (insinuated) cultural differences and forgets to take into consideration structural
issues, such as patients’ inclusion in a host society. Future research seeking to better understand
the impacts of patients’ characteristics and cultural differences on the MHSR needs to be designed
236
very carefully so as not to fall into the trap of culturalisation and essentialisation and risk creating
stereotypical images of a certain group of patients.
A fourth limitation of this dissertation, which links to the previous issue, concerns the
difficulty, present in both sections, of obtaining systematic, contextual and background data,
particularly on patient records. In Section I, the QES, there was insufficient data available in
primary studies, to enable a comparison of findings across the diverse resettlement contexts, or
regarding patients’ characteristics. The issue of restricted information on participants and contexts
provided by primary studies was discussed in Chapter 3 and has already been stressed as a challenge
for qualitative evidence synthesis by others (Paterson et al., 2001; Thomas & Harden, 2008). In
Section II, in the investigations in Brazil, many of the participants worked on a voluntary basis and
did not routinely keep records on their patients. Therefore, contextual information, such as a mean
of the number of patients per psychologist or of therapy duration could not be provided. In Brazil,
this is a broader issue – the healthcare system has been described, in general, as struggling from a
lack of interconnectedness and systematisation. For instance, only since 2009 have Brazilian
psychologists been obliged to keep systematic patient files (Böing et al., 2009; Marsillac et al., 2018).
Professionals who participated in this dissertation, shared how the missing information about who
was providing what sort of support, for whom, where, and for how long, and the associated absence
of collaboration, networks and interconnectedness of projects and the different parts of the system
hindered their work. Services were depicted as shattered, and sometimes professionals, working in
the same city in the area of MHSR did not know about each other’s work. As working in
interdisciplinary networks has been found to be a major helpful aspect in the MHSR for
professionals, knowledge of the existence of other professionals and services in the field seems
utterly important. Future studies and efforts are needed to provide and to spread more systematic
information on already existing services, projects and on professionals active in the MHSR and
related fields, such as legal counselling for refugees. Thereby, mixed-method designs may be of
special use – qualitative approaches could, on the one hand, be used to identify relevant projects,
services and gatekeepers, and patients’ trajectories in the system. On the other hand, quantitative
approaches could allow the generation of an overview and systematic understanding of the project
and service landscape of mental health support for refugees in Brazil.
The fifth concern could be that I myself am a female Western psychologist, who grew up
in a predominantly White, eastern German city acquiring German as my first and native language.
Considering the history of colonisation in Brazil, and what the playwriter Nelson Rodrigues
denominated the “complexo de vira-lata”, the so-called “street-dog or mongrel complex”, (De Souza, 2013;
Rodrigues, 2014) – a tendency of Brazilians to place themselves in an inferior place in front of
other, particularly European, nationalities – my German origin may have limited the amount to
237
which participants in Brazil felt comfortable in expressing their own opinions (González & Lincoln,
2006; Watters, 2001). Furthermore, critics may feel that any research in non-Western countries that
is led by a Western researcher is parachuting research – research the aims of which are defined by
Western researchers who conduct their fieldwork in an “exotic” context, in order to leave and take
the data with them to foster their personal career in Western countries (Davies & Mullan, 2016;
Hook & Vera, 2020). Meanwhile, throughout the fieldwork and its preparation I took great care to
avoid these pitfalls – apart from having lived an extended amount of time in Brazil, learning the
language to a point that fluent communication was not an issue any more, my dissertation is based
on various stays at, and a wonderful cooperation with, the department of Migrations, Psychology
and Cultures (NEMPsiC) at the Universidade Federal de Santa Catarina. During the time I spent
at the department, I got to know the work of psychologists who work with migrants and refugees
in Brazil. I also had the chance to discuss with my Brazilian colleagues the unexplored issues in this
area in the Brazilian context. We formulated the research questions in these discussions, and
according to the scientific literature and with the support of my second supervisor who is a
Brazilian psychologist active in the area of migrant and refugee mental health. The interview
guideline was pilot-tested with Brazilian colleagues and interview questions were formulated very
openly to avoid the creation of response expectations. Prior to the interviews, I held informal
conversations with the participants, explaining my research and connection to Brazil, which helped
to establish rapport with participants. Finally, in all stages of analysis – the transcription of
interviews, the coding of the transcripts and the generation of themes – I was lucky to count on
the support of other Brazilian researchers as well. Yet, future research may focus to an even greater
extent on the teamwork and partnership with local psychologists and researchers when conducting
investigations in non-Western contexts, in order to strengthen international research collaborations
and avoid research concerns being framed by Western high-income countries only (González &
Lincoln, 2006; Kirmayer & Pedersen, 2014; Watters, 2001).
Finally, this research was focused on mental health support for refugee patients. Thus, it
dealt with a specific part of the refugee population that suffers from mental health problems,
disorders, psychological struggles and concerns. While this is needed and should not be viewed as
a contribution to a pathologising of refugees, or a medicalisation of their problems (Bracken et al.,
1995), we acknowledge that it is equally important to investigate and recognise the strengths, the
resources and profound resilience of refugees (Barros & Martins-Borges, 2018; Silva-Ferreira et al.,
2019; Papadopoulos, 2007; Sieben & Straub, 2018):
238
Ich spiele Pingpong mit Sprachen, Kulturen, Fremdheiten, fange die Bälle und schmettere sie zurück, reich
an Erfahrung, furchtlos, leicht und bejahre mein Emigrantenschicksal in seiner ganzen gnadenvollen
Tragweite.28
Irena Brežná (2014, p. 140)
28 “I play ping-pong with languages, cultures, foreigners, I catch the balls and kick them back, rich in experience,
fearless, easy, and affirming my emigrant destiny in all its merciful consequences.”
239
Practical Implications
‘Haben Sie auch ein Serum gegen die depressiven Kriege, die Diktatur der Ehe und den Wahnsinn der
Emigration? Impfen Sie mich damit.‘ Er streckte dem Arzt seinen schwabbeligen Arm hin und rollte den
Hemdsärmel hoch.29
Irena Brežná (2014, p. 44)
In what follows, the practical implications of this dissertation’s research findings are
delineated. The chapter addresses, firstly, the implications for professionals who provide MHSR,
secondly, the implications for university curricula, education and training of psychologists and
finally, structural implications of this dissertation.
Food for thought for professionals

For professionals, this dissertation might provide useful insights, such as that the mental
healthcare of refugee patients often implies the transcendence of boundaries – boundaries between
the internal therapeutic space and the external context, boundaries in the therapeutic relationship
and boundaries between therapeutic schools or orientations (see Figure 20). In order to best
support the refugee patient and to establish a trusting and caring relationship, professionals may
learn from this dissertation that they might have to move beyond their classical psychological work
and professional role when treating refugee patients. For instance, in some cases, psychologists
may have to attend to patients’ practical needs, or help patients by advocating on their behalf.
However, this transcendence of boundaries also constitutes a balancing act for professionals, as
they may, by attempting to improve the situation of refugee patients, fall into the pitfall of
assistancialism, become overly involved and overwhelmed, or create victim–saviour dyads
(Papadopoulos, 2001). Unavoidably, professionals will encounter structural limitations in their
work. They might get frustrated when becoming aware of the constant hurdles refugee patients
have to face in their daily lives in host countries, or when they themselves are confronted with
never-ending bureaucracy in the attempt to assist patients with problems. They may even
experience disillusionment with their own country – for instance, if they listen to patients’
experiences of xenophobia and discrimination. Advocating on behalf of patients can be one way
to reduce such feelings of frustration and disillusionment. For example, professionals may, in
29
'Do you also have a serum against the depressive wars, the dictatorship of marriage and the madness of emigration?
Vaccinate me with it.' He stretched out his flabby arm to the doctor and rolled up his shirt sleeve.
240
cooperation with other actors in the medical and social areas, influence decision and policymakers
by providing information on the refugee (mental health) situation in post-migration settings, and
by making suggestions for protective policies (Rousseau, 2018). Meanwhile, most mental health
professionals are part of the very host societies, communities, institutions and privileged groups
that perpetrate injustice, discrimination and human rights violations against refugees (Kirmayer &
Rousseau, 2010; Rousseau et al., 2008). This dissertation has sought to highlight a number of
factors and strategies that might help professionals develop an awareness of this issue, and facilitate
their balancing out of therapeutic boundaries in the MHSR. These factors and strategies involve a
transparency of one’s own limits, and particularly collective work strategies, such as group therapy,
teamwork, co-therapy, as well as support structures, such as supervision.
Furthermore, while there is a tendency in the field of Western psychology to individualise
and pathologise problems that are of a more global and structural nature (Drožđek, 2007;
Summerfield, 1999), this dissertation highlighted the importance of a consideration of the socio-
political context of patients and professionals in clinical work and mental healthcare settings. That
is not to say that refugees cannot experience mental illnesses and disorders on an individual level.
The point here is that psychotherapy and psychological care with refugees make it really apparent
that humans and their suffering are inserted into, and exist in interaction with, a context. Each and
every patient and professional is embedded in a context; however, in the work with refugees, the
external context becomes more immediately apparent than it may for general patients (Bohart &
Wade, 2013). The reason for this visibility of the contextual impact is linked to the main reasons
for refugees’ suffering, which are largely of a socio-political nature: Exposure to war, genocides,
famines, human rights violations, imprisonment, torture, flight experiences, and post-migration
struggles such as family separation, inadequate housing conditions, unemployment, high precarity,
discrimination, racism, asylum status insecurities etc. (Bäärnhielm et al., 2017; Goodkind et al.,
2014; Griffiths, 2001; Kronsteiner, 2017; Watters, 2001). Therefore, professionals could be
encouraged to develop an awareness of these roots of patients’ suffering, particularly of those that
can be traced to the immediate post-migration context, instead of relying purely on individual
psychiatric psychopathologies. As a consequence of such an awareness, mental healthcare
professionals might develop stronger political identities (Apostolidou, 2015; 2016a).
Training and education of mental healthcare professionals

Providing adequate mental health support for refugee patients in host countries may require
some adaptations in the education of professionals.
Firstly, the need for socio-political awareness and contextual thinking calls for a shift in the
education of psychologists that places a focus on “structural competency” (Gavranidou & Abdallah-
241
Steinkopff, 2007; Jordan & Seponski, 2018; Metzl & Hansen, 2014, p. 127). Since many mental
healthcare professionals have been criticised to possess limited awareness of how socio-political
developments, cultural frames of reference, systemic processes, and power relations influence
clinical encounters (Guzder, 2014), it seems a matter of some urgency to provide training in
structural competency. Such training might encourage psychologists’ reflection about the interplay
of refugee patients’ suffering with their context and the consequences for MHSR (Metzl & Hansen,
2014). Meanwhile, no amount of training can compensate for a lack of disposition in professionals.
For any psychologist working with refugees it thus seems essential to develop an authentic interest
in socio-political aspects of their practice and in “the (cultural) other”, as well as a genuine
disposition to encounter the refugee patient and build a “real” relationship with him or her (Gelso,
2014, p.119).
The first thing is to dedicate yourself to the work, to like the work, to have a passion for the clinical work,
for socio-poltical history too, because I think you have to have interest and at least a basic knowledge of
socio-politics and history (Psychotherapist, Curitiba)
Secondly, as the world is experiencing growing global movements of flight and migration,
and as the universality of psychological phenomena is increasingly being questioned (Henrich et
al., 2010), a psychological education that pays attention to cultural facets seems to become of
general relevance for psychology curricula in universities internationally (Griffiths, 2001;
Knobloch, 2015; Silva-Ferreira et al., 2019). In that sense,
cultural psychology is well positioned to help clinical psychology move beyond conceptualisations of mental
illnesses as products of solitary minds to thinking of it as contextually embedded in networks of local
meanings, norms, institutions, and cultural products
(Ryder et al., 2011, p. 963).
The self-reflexivity of psychotherapists regarding their own theoretical and cultural standing
(Kronsteiner, 2017; Tervalon & Murray-Garcia, 1998) could be enhanced by addressing, in the
education of psychologists from an early stage onwards, how psychological traditions are rooted in
specific cultures, and in specific ways of thinking about human nature and of conceptualising
mental health and healing (Christopher et al., 2014; Kirmayer, 2012a). There might be a need to
teach professionals about how mental health support is a social institution inserted in specific
cultures (McLeod, 2003) and about the fact that diagnostic systems are cultural products as well
(Gone & Kirmayer, 2011; Lewis-Fernández & Kleinman, 1994). Additionally, cultural humility and
its expression in the therapeutic space could be fostered in the education of mental health
242
professionals. For instance, professionals could learn to demonstrate openness to patients’

worldviews (Hook et al., 2013) and to acknowledge patients’ beliefs and own sources of help
(Kirmayer, 2004; 2012). This dissertation suggests that when teaching cultural awareness or
humility, education programmes are best advised to work with caution to avoid essentialisations,
generalisations and stereotyping (Watters, 2001). Instead, they might benefit from concentrating
on encouraging an attitude of flexibility in mental healthcare professionals and an openness to
explore and adapt to the particular situation, background and views of each refugee patient (Savic
et al., 2016).
Thirdly, the present thesis proposes that the education of mental health professionals,
particularly of psychologists and psychotherapists, might need a move away from a rigid adherence
to a single theoretical orientation (Castonguay, 2011). Instead, it may be helpful to promote
integrative approaches and a constant rethinking of familiar models of psychotherapy (Miller, 1999;
Murray, 2010).
Finally, in lieu of proclaiming psychology as a profession of single heroes fighting their
wars alone and in isolation, education programmes might benefit from a shift to stimulating
cooperation between mental health professionals, and to furthering collective work strategies, such
as teamwork and co-therapy. Moreover, it might be useful for professionals to learn in mental
healthcare training about the usefulness of working in interdisciplinary networks, in which one can
find personal and professional support, for instance to reflect upon own attitudes and assumptions,
and to deal with role boundaries. Encouraging the work in interdisciplinary networks might also
result in possibilities for professionals to transfer patients whose needs exceed the limits of their
own role and capabilities.
Structural considerations
In terms of structural considerations, there are three major points to make here. Firstly,
since the problems associated with the post-migration context make up a considerable part of
causes for refugee patients’ suffering, as this dissertation has shown, and can aggravate preflight
traumas and hinder healing (Cleveland et al., 2014; Momartin et al., 2006; Porter & Hasalam, 2005),
the importance of improving post-migration conditions in host countries cannot be underestimated
(Bozorgmehr et al., 2016; Watters, 2001). If the aim is to better the mental well-being and health
of refugees in host countries, the most impactful step might be to improve their post-migration
life situation by facilitating asylum procedures and family unity, by meeting basic needs, such as
adequate housing and food, by rapidly providing work permits, by supporting the community
insertion of refugees and by raising awareness in the general population about the situation of
refugees and against racism and discrimination.
243
Secondly, there is a need to augment the spending on and funding for mental healthcare
services for refugees worldwide, to guarantee access to therapeutic services and improve the
adequacy and quality of these services (Murray et al., 2010). Unfortunately, in Brazil, as outlined in
Chapter 4 of this dissertation, current tendencies indicate a contrary move – the country is
experiencing harsh cut-backs in public healthcare spending, including mental health (Doniec et al.,
2018), and shifts away from programmes that aimed to facilitate the life of migrants and refugees
in Brazil (Uebel, 2019). Very likely, these developments will have detrimental effects for the most
vulnerable parts of the population, including refugees.
Finally, greater emphasis should be placed on providing structural support for
psychologists who offer MHSR. Mental healthcare professionals treating patients who have
experienced trauma and find themselves in challenging post-migration situations, seem to be at risk
of developing mental health problems such as vicarious traumatisation or compassion fatigue.
Therefore, investing in support structures, such as regular supervision, intervision and
psychotherapy for professionals might be a required preventative measure. Furthermore, the
strengthening of interdisciplinary networks between professionals, consisting of psychologists,
psychiatrists, general practitioners, lawyers and social workers, may help to improve the adequacy
of services for refugee patients. It might also support professionals in a way whereby they can have
a stronger focus on their own professional role, transfer responsibilities and protect them from
constantly feeling overwhelmed by patients’ multiple and complex needs.
244
Reflections on a Meta Level – Science and Psychotherapy as

Cultural Products
There are these two young fish swimming along and they happen to meet an older fish swimming the other
way, who nods at them and says, “Morning, boys. How’s the water?” And the two young fish swim for a
bit, and the eventually one of them looks over at the other and goes, “What the hell is water?”
David Foster Wallace (2009)
The present dissertation aimed to be a contribution to a cultural-clinical psychology (Ryder et

al., 2011), challenging to some extent the dominance of Western and particularly Usonian
psychological research conducted on WEIRD samples (Henrich et al., 2010; Marsella, 2009). The
interviews with psychologists who work with refugees showed that an awareness and reflection of
one’s own insertion in a specific culture is utterly important in MHSR. I do believe there is a need
to transfer this call for an awareness of one’s cultural and contextual embeddedness to the
psychological sciences themselves. In other words, a recognition of the fact seems necessary that
the field of psychology with its historical roots in the middle classes of Europe, characterised by
certain specific and, at the same time, universalist theories and ideas about psychological well- and
ill-being, about family, gender, sexuality, marriage, and the concepts of normality and suffering, is
not neutral from a cultural point of view (Dimenstein, 1998; Moleiro, 2010; Warelow & Holmes,
2011). Whilst there has been increasing recognition that a skewed representation of the psychology
of human beings is caused by the reliance on WEIRD samples and the hegemony of Western
countries, particularly the United States of America, in terms of research, publications and
knowledge dissemination (Adair et al., 2002; Christopher, 2014; Henrich et al., 2010; Moghaddam,
1987), much of the discipline still seems to remain unaware of how its historical and cultural roots
have shaped and are still shaping psychological research and theory (Christopher, 2014;
Dimenstein, 1998). For instance, the focus on an individual, that is an ahistorical and abstract self,
detached from his or her social context is still a dominant image in psychological science
(Dimenstein, 1998). Meanwhile, this image emerged in a very specific historical, economic, cultural,
scientific and societal context. Globally, there are very heterogeneous approaches to psychology as
a science, and different cultures of science more generally, which all stand in their own right. The
internationally diverse intellectual and scientific traditions are linked to a society’s history, specific
literacy practices, to structures of communities and to cultural characteristics in general
(Koutsantoni, 2005; Mauranen, 1993; Vassileva, 2001). Galtung’s (1981) intellectual styles which
were described in Chapter 3, are but one indicator of this plurality in the sciences. In the context
245
that predominates academic research in psychology, the anglophone world, principles of positivism
and empiricism are deeply encoded (Bennett, 2010). In contrast, in the Romanesque realm, such as
in France and in Brazil, psychology is often considered a qualitative subject-based science. There
have been calls for a heightened awareness that cultural, historical and societal contexts influence
intellectual thought and how science and research are conceived, carried out, interpreted and
evaluated, and also for the fact that there is not merely one single way of doing science (e.g. Ahearn,
2000b; Eastmond, 2000; Kirmayer, 2007; Summerfield, 1999, 2008). Maybe this is something
scientists in the discipline of psychology can take away from the context of migration and flight as:
Living with different, and, at times, contradictory, language perspectives means living with a sense that there
never was one singular truth.
(Daniel, 2012, p. 106)
In that sense, this dissertation calls for an acknowledgement of the diversity that exists
globally to approach the psyche, psychology and human beings, and for a fostering of a nuanced
interculturalising of psychotherapy and mental health research – an interculturalising that takes into
consideration different ways to approach science in and of itself, and to conceptualise mental
health, diagnostic systems, psychological suffering and psychological healing in particular, without
imposing one specific way:
Thus, I say to all psychologists – Western, Eastern and In-Between – recognize the historical and cultural
contexts of your knowledge and practices. See them as ‘cultural constructions’ relative to time, place, and
person. Though you may yearn for the comforts of certainty, this is not possible for our field of knowledge.
But this is not a cause for grief nor sorrow. Rather, it is a recognition that has made for the very advances in
knowledge we respect.
(Marsella, 2009, p. 26)
246
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Mental Health Support For Refugees - Integrating Brazilian Perspectives

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2020

Gesa Solveig Duden

Mental Health Support for

Gesa Solveig Duden

born in Bremen, Germany

1st Prof. Dr. Dr. Josef Rogner (University

2nd Prof. Dr. Lucienne Martins-Borges

En 2014 encore, cinq millions cinq-cent-mille nouveaux réfugiés

Tant de guerre, tant de victimes

Rokia Traoré, 2016

und weniger individuumszentrierte Perspektive in der Psychologie einzunehmen,

A Rationale for Investigating Experiences in Brazil ...................................................................105

Je suis ici, ainda que não queiram não

Luedji Luna (2017)

Displaced people (millions)

The Structure of the Dissertation

1 Also referred to as Ethnopsychoanalysis.

Some Thoughts on Terms Concerning Migration

Refugees and Mental Health

Prevalence of mental disorder among refugees

Migration, culture and mental health

Transformative processes affecting migrants’ self-concepts and identities, as well as the

7 Written by Margaret Nagle and directed by Philippe Falardeau (2014)

Mental health and the post-migration situation

The refugee journey. Adapted from Codrington et al., 2009, p. 130

Post-migration stressors for refugees in the post-migration situation include, in addition to

Psychotherapy, psychological care and counselling as types of mental health

a primarily interpersonal treatment that is a) based on psychological priniciples b) involves a trained

As there is no universal, international agreement upon the difference between psychological

What distinguishes MHSR from other forms of mental health support?

Culture and complexity in the therapeutic space

French ethnopsychoanalysis combine a psychoanalytic perspective on the conscious and unconscious

Ethnopsychiatry serves as a number of psychological approaches to look at human beings,

Research on mental health support

Research on mental health support for refugees

The need to integrate non-Western perspectives

(Kirmayer, 2012b, p. 160)

(Marsella, 2010, p. 19)

(Gone & Kirmayer, 2010, p. 74)

Aims of the dissertation

a. What do they see as negative aspects or barriers in the care process?

Disciplinary and epistemological localisation and methodology of the

Section I: A Qualitative Evidence Synthesis

Section II: Semi-structured interviews with experts

(Malterud, 2001a, p. 397)

(Hill et al., 2005, p. 197)

Mental Health Support for Refugees –

Keywords: Refugees, Transcultural Psychology, Systematic Review, Intercultural Research,

“Qualitative Evidence Synthesis” (QES) approach

Description of included studies and their participants

Data use and analysis

Authors, Date Origin Research Focus Analysis Sampling MHS Strategy/Status

Al-Roubaiy et al., 2017 10 P Iraq (10) M: 10 Mean: 32 Refugees Mean: 10.2

Note. Clusters only mentioned by PSPs are depicted in italic.

Cluster Descriptive Theme Evidence in Studies Patients

PSP giving information on resettlement country MI, PU, SC PSPs

B. What are negative/hindering aspects in the therapeutic process?

Cluster Descriptive Theme Evidence in Studies PSP or

B3. Bad or limited MHS in country of origin MAJ, VI Patients

Abstinence & neutrality do not work SC PSPs

C. What are ambivalent aspects in the therapeutic process?

Cluster Descriptive Theme Evidence in Studies Patients