Bridging between worlds in Switzerland – the promise of transcultural psychiatry

In 2015, when Amadou, a fifteen-year-old Guinean boy, reached Switzerland, he was hospitalized with strong antipsychotic medications. He had developed life-threatening depression, suicidal behavior, and severe bouts of psychosis.

Bridging between worlds in Switzerland - the promise of transcultural psychiatry
Photo: Appartenances

Just five years later, in 2020, his life is strikingly different. He has made many friends, goes to work every day, and can afford to live in his own flat. He says the reason is his psychiatrist, who delivers culturally appropriate mental health care for migrants, also known as ‘transcultural psychiatry’.

This article is part of Changing the Narrative. Articles in this series are written by student or early career journalists who took part in The Local's training course on solutions-focused migration reporting. Find out more about the project here.

“My psychiatrist saved my life,” says Amadou. “Before him, I wanted to commit suicide, and without him, I would not be speaking with you right now.

“If I had to tell you everything he’s done for me, we would end up speaking all night. He helped me find a job, get my driver’s license, and most importantly, he gave me the courage to call my mother for the first time in three years.”

Amadou’s story reflects the rough reality that many migrants face as they reach places like Switzerland, the country with the largest share of migrants in the whole of Europe.

Despite being one of the richest countries in the world, there is “clear evidence” that some migrant populations, especially refugees and undocumented migrants, still struggle to enjoy the same quality of mental health as the rest of the Swiss population, warns Denise Efionayi from Neuchatel University, who co-authored the country’s latest report on migration.

While massive disparities have existed for years, local tools that could bridge the gap, including culturally appropriate psychiatry services, are not yet mainstream – even though they have run for over two decades in Switzerland.

Shedding light on such life-saving services seems more critical than ever, especially as coronavirus-imposed restrictions batter mental health services and exacerbate existing inequalities.

Photo: Appartenances

Transcultural psychiatry: A bridge between two worlds 

Transcultural psychiatry is a sub-branch of psychiatry that responds to the diverse cultural backgrounds that migrants have, as well as their life experiences that can sometimes include abuse, torture and war. 

“Transcultural psychiatry is a sub-speciality of psychiatry that acknowledges the cultural background of patients, and adapts to work within the patient’s framework of health and disease, rather than imposing a Western view of psychiatry on the patient,” explains Dr. Felicia Dutray, who is at the helm of transcultural psychiatry services at Appartenances, an NGO in Lausanne partially funded by the Canton of Vaud.  

“If a patient believes that his mental health condition is due to bad spirits, we don't judge him for it,” she adds. “Instead, we acknowledge that his framework is valid, and try to understand what it means for him so that we can work with it.”

For almost three decades, Appartenances has catered to the mental health needs of migrants in the French-speaking part of Switzerland, receiving nearly 800 patients a year. Like all psychotherapy in Switzerland, services are paid for by insurance companies.

During most sessions, Dutray is assisted by professional interpreters to overcome potential language barriers, or to help the patient understand the aims of psychiatry and psychology, which are Western concepts sometimes unfamiliar to patients.

After two decades of working in the field, she is convinced that transcultural psychiatry benefits patients.

“People feel relieved after sessions, and they keep coming in, sometimes for several years,” she notes. “In many cases, people’s symptoms even reduce, and this is clear from our internal evaluations with patient questionnaires before and after sessions.”

One of the co-founders of Appartenances, Dr. Jean-Claude Métraux prefers to avoid using the term “transcultural”. Instead, he refers to his work as “bridging between the worlds of patients and doctors”. 

Although Métraux is no longer officially affiliated with Appartenances, he still delivers training sessions on migrant mental health for the NGO. In 2019, 1,400 people received some form of training, most of them social workers and health professionals, as well as interpreters.

Apart from delivering training, Métraux also runs his own private clinic. Like Dutray, he is a strong believer that therapy must extend beyond the realms of the consultation room. Sometimes, this may involve getting in touch with lawyers and social workers to help patients with legal paperwork, or even finding a flat.

“The idea is to go further than the office, and to foster participatory collectives where people feel recognized in a nurturing environment,” says Métraux. 

It is perhaps not a coincidence that Appartenances also offers social spaces for children and adults, three of which are exclusive to women. These collectives help migrants build their own networks, become autonomous, and integrate into society through a range of fun and useful activities, including art workshops, French classes, or even IT skills. 

Photo: Appartenances

Recognising patients as equals

Establishing mutual recognition with patients is crucial, says Métraux as he reflects on his work.

He argues that, before any diagnosis can be made, doctors must first establish “mutual recognition” with patients and understand the social, political, cultural and juridical context that often shapes their health.

His comment is particularly pertinent given mounting evidence that migrants are often misdiagnosed, precisely because psychiatrists miss important contextual details during consultations. As a result, the quality of care they receive takes a big hit, studies show.

Discrimination, for instance, can trigger an auto-exclusion syndrome that is sometimes confused with psychosis in migrant populations, he adds. But once patients are recognized as equals by their doctors, their psychiatric symptoms can even attenuate in some cases, says Métraux.  

“A lack of recognition is a deep-seated problem in society that exacerbates mental health issues of migrants,” he says. “This is why it’s so important to offer patients a context where they feel recognized, in the clinic and also outside the clinic.”

While his emphasis on mutual recognition may seem far-fetched to some, it is consistent with data on discrimination and mental health in Switzerland. Migrants that make it to Switzerland are more lonely, and three times as likely to experience discrimination, in comparison to locals without a migration background, says the Federal Office of Public Health.

“We know that mental health and discrimination correlate quite strongly in some migrant populations, but not all,” adds Efionayi.

Métraux emphasizes that mutual recognition can only be established when difference is seen as an asset, rather than a deficit. He also warns against labelling migrants as ‘vulnerable’ because it implies that others are invulnerable, thus creating the power asymmetries he is so motivated to break down. 

In his sessions, he even goes as far as to share his own vulnerabilities to forge a bond with his patients. He also works hard to empower his patients to recognize their capacities, and their inherent ability to take control of their lives.

“To treat each other as equals, we need to show our vulnerability as doctors, and stop seeing difference as a deficit, as it is commonly done.”

Stockholm’s promising approach to migrant mental health: 'Mainstreaming'

Switzerland’s example is just the tip of the iceberg when it comes to delivering culturally appropriate services for migrants, refugees and asylum seekers.

Up north in Sweden, where migrants make up about 20 percent of the overall population, Stockholm’s Transcultural Centre has catered to the needs of migrants for over two decades, says Dr. Sofie Bäärnhielm, a leading psychiatrist, and director of the centre since the early 2000s. 

She says the Transcultural Centre fills the vacuum of expertise in migration and health, especially in medical schools, where there is “very little” training in cross-cultural services.

Unlike Switzerland’s Apartenances, The Transcultural Centre operates exclusively as a knowledge centre that offers support and training in the field of migration and mental health, especially for asylum seekers, refugees or undocumented migrants.

During training sessions, one of the Centre’s favorites is the cultural formulation questionnaire, which is routinely used around the world by healthcare and social workers to better understand a migrant’s context, including at Appartenances. It was designed in North America, and incorporated into the fifth iteration of the Diagnostic Statistical Manual for Mental Disorders (DSM) several years ago.

When it comes to training, the Centre’s approach is rather special, as it extends beyond psychiatrists, health professionals or social workers – it also strives to train teachers, workplaces, churches, NGOs, or anyone else that is interested in migrant health, says Bäärnhielm.

In fact, the Centre’s mission is to “mainstream” cross-cultural skills into Swedish society so that it becomes responsive to the diverse needs of migrants.

“Our mission is to embed cross-cultural skills into Swedish society, as migrants don’t just interact with healthcare,” she says. “They interact with the whole of society, and that’s why the whole of society must become more responsive to their diverse needs.”

Mainstreaming cross-cultural skills across all sectors is a particularly important strategy, comments Dr. Inka Weissbecker, a WHO expert in mental health. She says it could take the edge off overwhelmed mental health services, and also prevent migrants from having to see a psychiatrist in the first place. She explains that such whole-of-society approaches can make mental health support and care more widely available and accessible, while also addressing some of the root causes of poor mental health. 

In 2019, the Transcultural Centre trained over 4,200 people, including healthcare workers in outpatient clinics, nursing wards, as well as workplaces and NGOs, among others. Since the coronavirus struck, the centre has maintained its efforts, albeit through Zoom, with funding from Stockholm’s authorities.

Photo: Appartenances

No perfect solutions

Although Amadou’s life has taken a new turn since he began therapy, since he began cross-cultural therapy, it doesn’t work for everyone, and outcomes may depend on a migrant’s context, which can be highly dynamic, warns Dutray. She notes that an unsuccessful asylum request can have devastating effects on mental health, irrespective of a psychiatrist’s calibre or the length of therapy.

Local evaluations of transcultural psychiatry services are also difficult to achieve, mainly because they are expensive and logistically complex to conduct – especially for NGOs like Appartenances, she adds. Even when resources are available, it can be difficult to recruit patients, notes Dutray. “If you don’t know where you’re sleeping or don’t have papers, you’re unlikely to take part in a study.

On the upside, one robust evaluation of a cultural consultation service in 100 patients showed that it can respond to the needs of diverse populations, improve diagnosis and treatment outcomes. The evaluation was published in the Canadian Journal of Psychiatry, and is one of many that have been produced in the past seventy years since transcultural psychiatry was developed.

Amadou was hospitalised when he arrived in Switzerland as a 15-year-old. Photo: Private

Although today, transcultural psychiatrists have access to robust questionnaires like the cultural formulation questionnaire, the original English version must be translated and adapted for different contexts – and this requires considerable expertise that is not always available, warns Bäärnhielm. She recounts when the questionnaire was first introduced to Sweden, and how difficult it was to translate concepts like “race”, which is a controversial term in Sweden, and to make sure that the translated questionnaire was useful for its users.

Funding is another issue, as delivering specialized mental health services for migrants is “not exactly lucrative”, so there is little incentive to pay for high-quality training or research, said a Swiss expert familiar with the topic, who asked to stay anonymous.

“Transcultural psychiatry is a totally different ball game compared to having a profitable private clinic for patients that can afford to pay,” said the expert. “As a result, transcultural psychiatry curricula are limited, there is a lack of high-quality training, and systematic evaluations of effectiveness are also scarce, as nobody will pay for it.”

In Sweden, culture-responsive mental health services are also the exception rather than the rule because there is simply not enough interest, says Bäärnhielm. One way forward, she suggests, could involve strengthening migrant health advocacy, as it is still fragmented and resource-poor.

Following his undergraduate studies in biology, Svĕt Lustig shifted gears to study public health at the London School of Tropical Hyigene and Medicine, alongside weekly reporting for Health Policy Watch, an open-access news service based in Geneva. He was born in Switzerland, and is half-Czech and half-Indian. 


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A cultural exchange programme for the ‘forgotten Spanish colony’

The people from Western Sahara have been fighting for their independence for decades. Under the control of Spain for over a century until 1974, Western Sahrawis were able to have a Spanish National ID and passport, to serve as public servants and in the army, with the western Sahara declared by fascist dictator Francisco Franco as the 53rd province of Spain.

A cultural exchange programme for the ‘forgotten Spanish colony’
Some of the children participating in the programme experience health conditions caused by the tough life in the refugee camps. Photo: Sonia Clemente
This article is part of Changing the Narrative. Articles in this series are written by student or early career journalists who took part in The Local's training course on solutions-focused migration reporting. Find out more about the project here.

In 1974, after pressure from the UN, Spain agreed to a referendum to accept the Sahrawis’ right to self-determination. But when Morocco, supported by France and the U.S., invaded the country, Spain abandoned the Sahrawis. Nowadays, 80 percent of their country is occupied by Morocco, and hundreds of thousands of its citizens are stranded in refugee camps in Algeria. The result is that people living in this region are denied the same rights given to other former colonies, such as the ability to claim Spanish citizenship.

Today, the fifth of the country that is not controlled by Morocco is known as the Sahrawi Arab Democratic Republic (SADR) and it is governed by the Polisario Front, recognised by 46 governments around the world, although none in the EU. In Spain, some local organisations and public figures campaign for their government to support the Sahrawi people.

“Spanish citizens have stood next to the Sahrawi people for 45 years because they understand that Spain has a political and legal responsibility with the Sahrawi people, but they see their political leaders incapable of amending this error. It is the great divorce in Spain,” Abdulah Arabi, the Polisario Front Delegate in Spain said, “Spaniards are holding a responsibility that belongs to their government.”

At the time of the interview with the Sahrawi Delegate, Abdulah Arabi expressed concern that they were closer than ever to a break of the truce. Two weeks later the truce broke. “We have generations that have been born in refugee camps waiting for the UN to apply their peace plan so their parents and grandparents can decide what they want to be.”

Photo: Sonia Clemente

Holidays in Peace

One of the most successful programmes trying to both improve the conditions of the Sahrawis in refugee camps and to bring awareness to the conflict is Holidays in Peace. It allows Sahrawi children living in Algerian refugee camps, in one of the roughest deserts in the world, to live in Spain for the summers with host families.

This programme allows kids to avoid the desert heat, and access medical treatment and check-ups. It also helps them to learn Spanish, the second official language of the SADR. 

The programme began in 1976 with just a handful of children, and only three years later, 100 children spent their summers in Spain. In the 1980s the initiative gathered institutional support from the SADR government and several Spanish civil associations under the umbrella of “Friends of the Saharawi People.”

By the early 2000s, thousands of kids would travel every summer.

“In the good year before the 2008 crisis when the [Spanish] government donations were larger, we were able to bring up to 10,000 children every summer,” Arabi said.

Many of these children come back for several summers and stay with the same families again. When the children return to the camps, the host families often visit and send care packages. The associations also send vans full of supplies a few times a year to the camps.

Raúl Bedrina, who joined one of the associations in Madrid, and later helped to create the Gdeim Izik association in the south of the Spanish capital, hosted a child for the first time eight years ago.

“It is not charity, it is solidarity. These children are the best ambassadors of the Sahrawi people, who share a common history with us,” he said.

Western Sahara is the only Arab country with Spanish as a co-official language. However, the language barrier is still a challenge for the children, as they only began studying Spanish around the same time that they travel for the first time.

“At that age, kids are like sponges, in two months they are fluent,” Bedrina said, “but we put in the effort, too. Every day for one or two hours before going out or to the pool, we would sit with a picture dictionary and helped him.”

Bedrina talks about the cultural shock the children suffer when they arrive. The first thing they want to do is call home.

“Our kid went to bed crying for days because he missed his family. It’s also very odd for them to see things like a refrigerator, and they keep checking to see if things are still cold,” he said. They are also used to much more independence, to just go out a run around without supervision “but if only because of traffic, that is not possible here.”

“The ties you, as a host family, establish with the family are very strong. They are sending their children to a house they don’t know, so they want to know you.” Many of the host families visit the camps to meet the Sahrawi family, and the families want to send their other children to the same host family. “Our kid was the one who sold us the idea to host his younger sister. He took us for a ride,” Bedrina remembers, laughing.

Each host family is assigned a Sahrawi family, and they get to know each other as part of the process.

These children are not orphans, they have families who love and care for them, and it has to be made clear to the host families that the children will come back to their families after the summer. There are other programmes for teenagers who come to study in high schools during the school year and who go back home for the summer, but it is a much smaller programme.

The 2008 economic crash affected the programme a lot. Local governments cut the funding given to each association and they found it harder to fundraise money during the year. Many families who had hosted kids in the past couldn’t host those years because they were suffering from unemployment or financial troubles.

Most host families are middle class and the weight of an added member in the household was too much for many of them. “Kids come with nothing,” Bedrina said, “you have to give them clothes, food, et cetera…”

Because of this, the number of years the children would travel was reduced from five to three, so more children could continue to travel. However, it still cut the number of children able to travel by more than half for some years. Things had started to improve in this respect, but then Covid-19 hit.

An outdoor prison

The conditions in the desert are very dire. “There is no vegetation, no water, and temperatures go higher than 50 degrees,” Arabi said.

Before Covid-19, there were two times a year where host families could travel to the camps, around Easter around Christmas. For Bedrina, and many families, although hosting a child has been quite an experience, nothing compares to visiting the camps, and seeing the conditions.

“All Westerners should go and see a refugee camp to open their minds about what is going on in the world. I have seen colleagues go there and feel completely overtaken by the injustice and the world would fall on them. It was too much for them,” he said. Bedrina has been three times to the camps, not only meeting the families but also interviewing women about their vision on the conflict for a documentary and bringing humanitarian aid collected in Spain.

Photo: Sonia Clemente

Bedrina described the camps where Sahrawis have been living for 45 years as “a giant outdoor prison. It is difficult to describe with words.”

“The first days there I thought I had a cold because I was having trouble breathing, but then I realized it was the sand dust I had been swallowing all day,” he said

David Pobes, another volunteer in an association also travelled by car to the camps to take donations gathered in Madrid. He lived with the family he had been in contact with. “You live with them, and you can see they have nothing. The homes usually have two rooms. Not two bedrooms, two rooms. There is no furniture and they sleep on the floor. While you are there you eat with them, cook with them, and clean with them,” Pobes said.

'Saved many lives'

While the main objectives of Holidays in Peace are building awareness of the Sahrawis’ situation, and to take the children away from the camps during the hot summers, one of the key aspects that have helped save lives is the access to better medical care and nutrition during the summer.

Healthcare is a scarce resource in the camps. “We have a Ministry of Health that guarantees health in all the towns in the camps. But the dispensaries are indeed basic,” Arabi said. When David Pobes visited one of the clinics in the camps, he was surprised by it: “in one room, they had an old gas refrigerator for insulin. That was the best technology I saw.”

The clinics are meant mostly for first aid. If it is more serious, the patient must go to the province hospital or the national hospital. If it is even more serious, they must be transported abroad. However, access to specialized medicine is rare.

During the summers in Spain, the children get a full check-up with a blood test and access to specialists. “Thanks to these check-ups we have been able to save many lives of children who are now living a normal life, thanks to this programme,” Arabi said.

Spain has universal healthcare, meaning that the children can access the Spanish healthcare system upon arrival. Children in the camps suffer from hearing and sight problems because of the sandstorms. “You wouldn’t believe the stones that I have seen taken out of these children’s ears. Stones!” Pobes said.

When it comes to sight problems, the associations run fundraisers the entire year not only to cover the €600 flight but also glasses these kids might need. Some optometrists provide the glasses for free for these kids, but unfortunately, there are not enough.

Adapting to the pandemic

Due to Covid-19, the programme was cancelled for the first time since it began decades ago.

To alleviate the effects of not running the programme, the Polisario Front came up with an alternative list of events in the camps. During July and the first half of August children in the refugee camps have taken part in cultural and sports activities.

“We have done practically everything they would do here, such as medical check-ups, but, of course, conditions are not the same, as structures are fragile there.” Arabi said.

They took part in poetry and music workshops, football, cross country, and a programme of exchanges with older people who told them their life stories. They have been able to offer this version of the programme to all the children in the camps, around 9,000.

In August a group was taken to the liberated territories. It was the first time they could see them. Arabi said the programme was a bit rush, as they couldn’t be sure what the Covid conditions were going to be or if they would be able to do it at all, “but the results have been good.”

The plans for next summer remain uncertain, but the hope is that it will be able to return to its usual format, providing many children with a connection to a Spanish host family, language lessons, medical care and a break from life in the camps.

Thess Mostoles is a Spanish journalist currently living in the UK and reporting on international politics, war and conflict.