Practical tips for conversation and clarification

A good doctor-patient relationship, interest, impartiality and empathy are important prerequisites for dealing with traumatized migrants. Psychologizing explanations should rather be avoided.

A part of the migrants in our country come from living environments that are characterized by poverty, neglect, violence and war. Emigration and a completely new start in a foreign environment are an enormous burden for these people and place high demands on the adaptability of individuals and families. Traumatized immigrants are more psychologically and physically vulnerable compared to the average population. Among other things, they have a significantly increased risk of developing mental illnesses such as depression, somatoform pain disorder, or post-traumatic stress disorder [1]. Family physicians have an important function in the assessment and treatment of traumatized migrants, as they are usually the first medical point of contact for these people. Especially in very tense patients with changing complaints and strong vegetative reactions, one should always think about the possibility of suffered traumatization. In many cases, successful care of such patients by primary care physicians involves cooperation with other specialists such as psychotherapists, social workers, aid organizations and integration officers.

What brings traumatized immigrants into medical practice? Backache, headache, and other musculoskeletal pain conditions often top the list, followed by stomach problems and sleep disturbances [2]. Family physicians often feel unsure how to address mental health issues, trauma, or torture when speaking with refugees. They suspect strange ideas of illness or fear strong reactions when addressing traumatic experiences. In asylum seekers and recognized refugees who come from countries with frequent human rights violations, the following symptoms direct suspicion to mistreatment or torture they have undergone:

Chronic pain and discomfort of variable course (including musculoskeletal, head, stomach, genitourinary tract); symptoms are often presented with significant distress
Visible consequences of injuries (scars, eardrum perforations, foot deformities)
nervousness and vegetative overexcitement (sweating)
Chronic sleep disorders (anxiety, nightmares with motor restlessness and crying).
Expression of fear, anger, mistrust, resignation and powerlessness (also as countertransference feelings)
Frequent physician changes and/or emergency consultations due to changing symptoms.

How to communicate, how to investigate?

Examination interviews should be conducted in a trusting atmosphere in a gentle and predominantly patient-driven manner. The space, seating arrangement, and demeanor of the physician should convey a sense of security; unnecessary stress and potential triggers such as long waits or being left alone in a room should be avoided. The communication style of the professional should convey empathy and transparency; listening and actively conveying comprehensible information should be balanced. The manner of expression and the style of speech are to be adapted to the counterpart as far as possible, but without being ingratiating or infantilizing. The use of technical terms as well as premature pathologization – especially with psychological terms – should be avoided [3,4]. Traumatized migrants usually find it difficult to speak concretely about their experiences and symptoms. Some fear being seen as mentally ill or losing control. Only when a sustainable basis of trust has been established do these people begin to talk. It is a good idea to let the patient decide when to start talking about what he or she has experienced. The following tips will help you get started with this difficult topic more easily:

Ensure linguistic understanding: Mutual understanding should be adequately ensured not only in simple factual matters, but above all in emotionally stressful topics. If possible, consult an independent translation aid [5].
Provide information: Explain your intentions in simple and clear terms. Orient openly about the process and goals of the examination as well as the patient’s rights (e.g., medical confidentiality).
Communicate safety: When arranging seating and in the examination situation, keep in mind the person’s unspoken need for security. Observe escape routes and distance, carry out calm movements and establish any necessary physical contact in a determined but careful manner.
Do not “interrogate.” A medical examination can act as a key stimulus (trigger) for traumatic re-experiencing. Avoid conducting interview-style conversations and extracting information from patients too investigatively
Avoid activism: Don’t be rushed into special investigations. Often there are sufficient findings from previous examinations (medical history!) and certain technical procedures may trigger torture memories. Once a relationship of trust has been established, examinations such as CT, MRI or EEG are also reasonable and are usually tolerated without problems (after good information).
Have time and patience: Many things can only be discussed once a relationship of trust has been established. Let them take the initiative in deciding what to say and how much to say. It is very important for traumatized people to have a sense of control over the situation. Don’t catch patients off guard with surprise questions or suggestions
Thinking about loved ones: include patients’ spouses and children in your considerations: “If you startle at night, … if you’re nervous during the day and not very resilient, … if you could fly off the handle, … what’s it like for your wife or the kids?”
Consider real life situation: Be interested in the living conditions in the home country, reasons for migration, history of flight, history of integration, and plans for the future. Many migrants bring specific skills with them and have associated expectations and hopes with migration that do not correspond to their current life situation. Real current life difficulties such as residency status, poverty, problems with employment and education, or child rearing subjectively burden some patients more than past trauma [6].
Interest in “patient agenda”: inquire about patient’s ideas about disease and address them without bias. On the one hand, these ideas express the medical concepts acquired in the home country; on the other hand, they also reflect traumatic experiences: “The pain comes from the damp cell, from the countless blows”; “I was threatened that I would never again be able to have sexual intercourse without pain”; “They injected small metal splinters into my body; over the years, these will travel to my heart and thus kill me”.
Addressing experiences of violence and traumatic experiences once a relationship of trust has been established: A possible introduction to the sensitive topic could be: “I know that many people in your home country are severely mistreated by the police or other security forces. Have you experienced something similar and would you like to talk about it?”
Address and explore psychological symptoms directly: In contrast to body symptoms, people are less likely to mention their psychological symptoms spontaneously. An active approach relieves the burden: “I know from other refugees who have experienced violence that they … suffer from persistent sleep disorders, … Have terrible fantasies or nightmares, … are afraid of going crazy, … are afraid of losing control over themselves. Do you know similar signs in yourself?”
Promotion of resources – avoidance of pathologization: The trauma reaction is to be understood as a basically normal mental protective mechanism to an extreme situation. Torture and war trauma victims should be made to feel, “I’m not crazy.” Unnecessary pathologization should be avoided. Emphasis on existing resources is intended to promote resilience and enable progressive development.

Pain

Closely intertwined with posttraumatic stress disorder (PTSD), depression, and postmigratory life problems [7] are pain conditions that are among the most common reasons for consultation in family practice. Chronic pain is seen in up to 88% of refugees with PTSD [8]. The pain may be generalized in the sense of a pain disorder or it may be localized; it may occur with observable physical findings but also without documentable findings. The pathophysiology of chronic pain involves different mechanisms: neuroplastic expansion of pain-mediating structures, central pain sensitization and mnestic anchoring of pain in terms of a learning process, pain reactivation and augmentation by fear [9]. Experiencing pain is one of the basic experiences of every human being; dealing with pain can be seen as the sum of life experiences. Each person faces pain alone, provided with all their personal resources, past experiences, confidence and fears.

Testimonials

In the care of traumatized, tortured individuals, the primary care physician is often called upon to provide testimonials. One should express oneself on the ability to work, comment on a retirement or otherwise enable a benefit with a medical certificate, be it a better mattress, an education, a larger apartment. Let’s remember that sometimes the family doctor is the only ally refugees know. They place great, often unrealistic hopes in the effect of medical testimonials. It is not easy to explain the very limited possibilities of medical influence in this country. One of the most difficult tasks is to comment on a person’s ability to work. As primary care physicians, we are sometimes familiar with the workplace and work settings in which refugees work; this can help us make specific statements about work capacity. However, we often rely on what the person says and should declare it as such. Assessments should be conducted by experienced assessors with knowledge and skills in dealing with traumatized migrants [10].

Knowing your own limits – interdisciplinary work

Family physicians often feel overwhelmed in the treatment of refugees and asylum seekers, challenged by both structural (language, lack of time) and substantive difficulties (trauma, flight history, integration problems). Reactions to being overwhelmed can include cynicism, exhaustion, polypragmasia, and subliminally discriminatory behavior. To avoid this, intervision and balint groups as well as quality circles are highly valuable. A collegial discussion of difficult situations, learning from each other’s experiences, sharing difficult situations are proven family medicine techniques in dealing with situations that threaten to overwhelm individuals. The family doctor should seek specialized help in good time: difficult, stressful situations should be referred to psychiatric treatment. Often, joint psychiatric-primary care will prove useful, at least during difficult periods.

Take-Home Messages

In migrants with changing complaints and high levels of tension, one should always think about the possibility of trauma.
A trusting doctor-patient relationship, interest, impartiality, and empathy are important prerequisites for exploring migrants’ trauma histories.
A calm and respectful demeanor, a transparent approach to examinations, and the communication of clear and understandable information enable traumatized migrants to build trust with the doctor.
Acknowledging the difficult life history and respecting the suffering are central to successful treatment; psychologizing explanations should rather be avoided.

Literature:

Steel Z, et al: Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 2009; 302(5): 537-549.
Burnett A, Peel M: The health of survivors of torture and organized violence. Br Med J 2001; 322: 606-609.
Kläui H, Frey C: Torture and war victims in family practice. Switzerland Med Forum 2008; 8(46): 891-895.
Schwald O, Smolenksi C: Traumatized refugees and torture victims in family practice. Prim Hosp Care 2016; 16(3): 55-58.
Morina N, Maier T, Schmid Mast M: Lost in Translation? – Psychotherapy with the use of interpreters. Psychother Psychosom Med Psychol 2010; 60(3-4): 104-110.
Patel N, Kellezi B, Williams AC: Psychological, social and welfare interventions for psychological health and wellbeing of torture survivors. Cochrane Database Syst Rev 2014 Nov 11; (11): CD009317.
Aragona M, et al: The role of post-migration living difficulties on somatization among first-generation immigrants visited in a primary care service. Ann Ist Super Sanita 2011; 47(2): 207-213.
Teodorescu DS, et al: Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study. BMC Psychology 2015; 3(1): 7.
Egloff N, Hirschi A, von Känel R: Pain disorders in trauma patients – neurophysiological aspects and clinical phenomenology. Praxis 2012; 101(2): 87-97.
Hoffmann-Richter U: Does migration make you sick? On the assessment of migrants with adjustment, stress, and somatoform disorders. SUVA-Med Mitteilungen 2002; 73: 64-77.