*3.4. Perception of Follow-Up Treatment*

The interviewees also described their motivation as well as facilitating and impeding factors regarding further therapeutic help outside the state registration and reception center following their move to municipal housing.


#### **4. Discussion**

This study aimed to shed light on refugee patients' perspectives on their psychological burden, use of low-threshold healthcare, as provided by the psychosocial walk-in clinic in a state registration and reception center in Germany, and their future help-seeking attempts regarding follow-up treatments. Our qualitative results show that psychological stress was mainly described on an emotional and cognitive level and less frequently voiced via psychosomatic symptoms. Additionally, participants emphasized the impact of postmigratory stressors as exacerbating contributors to their mental health problems. The majority of interviewees were satisfied with the counseling provided by the psychosocial walk-in clinic. Participants particularly appreciated the supportive, resource-focused, and trust-building conversations with the therapists, pharmacological treatment, as well as access to ancillary services, such as a stabilization group, and the receipt of medical reports. Prior recommendation and encouragement by others as well as the belief in the effectiveness of therapeutic support were named as factors facilitating psychosocial walkin clinic attendance. Perceived difficulties were mainly seen in structural barriers, such as the clinic's confined waiting area and the generally high noise level, as well as long waiting periods. However, interviewees also named internal factors, like feelings of shame and fear of stigmatization. Most interviewees felt motivated to seek further therapeutic support in the future. Regarding barriers to future therapeutic support, participants named internal difficulties, such as feelings of shame, fear of stigmatization, as well as language barrier-related concerns and lack of information about respective support offers.

Regarding their mental health, the interviewees most frequently stated psychological problems on an emotional and cognitive level and only named a few somatic symptoms. While several previous studies have suggested that refugees tend to express their psychological distress through somatization [35–37], statements regarding somatic complaints were less frequent than one might have expected in this study's sample. The symptoms described by the respondents can be seen as part of their mental illnesses, such as PTSD, depression, and adjustment disorder. Especially somatic symptoms, like heart pain or heart excitement (see Reference [36]), can often be somatic manifestations of the patient's world of affective experience. Our data suggests that our interviewees had a high awareness of mental illness as well as good symbolization abilities and did not seem impeded by the various reasons previously named to explain high somatization rates in refugee populations, which include social and cultural acceptability, fear of stigma, somatic rather than psychological symptom expression, somatization as a cultural sign of distress, and alexithymia [38]. However, our interviewees' good symbolization abilities, as in their ability of expressing emotions and understanding their somatic manifestations, might be explained by the fact that they were patients attending the psychosocial walk-in clinic for mentally burdened refugees and asylum seekers and, thus, are a rather more select group.

The burdening symptoms were attributed to past events and to post-migratory distress factors. This is in line with previous findings in which refugees have named past and flight-related experiences as well as stressful aspects of the current life situation as causes for their poor mental health [35,39–42]. For instance, in Zbidat et al.'s study [36], symptoms of insomnia or fatigue were linked to events like loss of one's family, possessions, and home. Further, post-migratory distress factors were associated with enhanced vulnerability for mental health problems [43–45]. Interestingly, previous studies have also identified supernatural and religious beliefs as important factors in their participants' theory of illness regarding their mental illness [46,47]. Spiritual or traditional belief systems regarding the causes of psychological symptoms may be associated with help-seeking behavior outside the healthcare system [48]. However, none of the interviewees mentioned any religious or supernatural factors in our study sample. This may be explained by the fact that mental health literacy increases with the use of mental health services [49–51].

In addition to psychological burden, interviewees reported various coping strategies, including social support or emotional and behavioral strategies. Religious practice was only specifically mentioned once. Social support and religion have been named as key

and preferred coping resources in previous studies, while seeking professional help was rare [39,40]. Interestingly, consulting a therapist/medical professional was a frequently cited coping strategy in our study. This could be explained by the fact that the psychosocial walk-in clinic is an established and well-accepted service in the registration and reception center. This may not only facilitate low-threshold healthcare access but also promote mental healthcare awareness as well as acceptance. Furthermore, the interviewees in our sample seemed to be rather open-minded towards professional medical and therapeutic help. This is reflected by the fact that 50% of the interviewees said they would have reached out for a professional in their home country. The fact that professional help was seen as so important may also be related to the fact that the other coping strategies alone were no longer experienced as sufficient to manage the increasing psychological symptoms. Especially, the early post-migratory phase holds multiple challenges, such as uncertainty about the asylum procedure, frequent reallocation to other accommodations, and having to start adjusting to a new country and a new environment. This can cause trusted coping skills to become inadequate.

Interviewees were hopeful about the prospective course of their mental state. Indeed, the majority expected to see improvement in the future. This is particularly interesting considering that negative cognitions and emotions, such as hopelessness, helplessness, and resignation, are frequently associated with the diagnoses of post-traumatic stress disorder, depression, and adjustment disorders [52]. Keeping in mind that optimism can impact mental well-being, this optimistic attitude is a valuable resource [45]. However, different longitudinal studies underline that mental healthcare needs are extremely high among refugees and asylum seekers [10,53–55]. For instance, Nikendei et al. [14] conducted a three-month follow-up study to assess patients' further course of mental health after attending the psychosocial walk-in clinic in the PHV. While they were able to show improvement in depression, panic, and psychosocial well-being, the levels were still clinically relevant. No changes were found for PTSD or generalized anxiety disorder. They further examined access to healthcare and concluded that while most patients had access to general practitioners and local psychiatrists, none of the assessed refugees had access to outpatient psychotherapy. Regarding the access to the psychosocial walk-in clinic, facilitating factors, such as recommendation and encouragement by medical or social staff members working in the PHV as well as other refugees, helped them reach out to the psychosocial walk-in clinic. Only a few interviewees came on their own accord. According to Asgary and Segar [56], stigmatization, shame, mistrust, low trust in mental health services, lack of information, and low health literacy are key internal impeding factors in mental healthcare access. Personal and professional referrals appear to raise awareness, motivate, and encourage affected individuals and reduce initial fears of stigmatization, not least by providing necessary information. Our findings suggest that the interplay of different mental health and medical organizations is of great importance to facilitate refugees' access to mental health services, especially with regards to overcoming barriers. Unfortunately, difficulties in recognizing and dealing with clinical and social problems, low between-healthcare provider inter-collaboration, as well as diagnostic insecurities often impede professional help [6,7]. In the present study, interviewees mentioned few barriers preventing them from attending the walk-in clinic. This may be explained by the clinic's low-threshold service structure characterized by easy accessibility, walk-in policy (no prior appointment needed), free treatment, and on-site interpreters.

Most interviewees were highly appreciative of the counseling sessions and felt that the conversations there helped them. In the literature, conveying hope and confidence, feelings of safety, trust, confidentiality, as well as respectful, appreciative encounters, form the foundations of positive therapeutic interactions [57–59]. Several authors argue that the importance of these relational aspects becomes even more significant due to the backdrop of the adverse and dehumanizing experiences refugees have suffered [58,60]. Accordingly, psychosocial work with refugees should be directed toward a therapeutic relationship that is conducive to trauma management. This is, in fact, very appreciative of

the professionals working in the psychosocial walk-in clinic. Particularly, since counseling sessions in the clinic are often the refugees' first experience of therapy, and expectations differ due to difficulties in distinguishing between the professional focus of psychologists, psychotherapists, psychiatrists, and general practitioners.

While the positive perception of psychopharmacological treatment found in our study is consistent with previous findings [61], biological components of mental health disorders were not explicitly represented in their theories of their mental illness. Frequently, inadequate mediation intake or low compliance can be a problem [62]. According to Nikendei et al.'s [14] follow-up study, 51.9% of patients had continued taking their prescribed medication three months after they had last visited the psychosocial walk-in clinic. Interestingly, medication was one of the refugees' least preferred coping strategies in Markova et al.'s [40] study. Here, older participants in particular were more skeptical towards psychopharmacotherapy. However, in our study, the respondents were around thirty years old. Consequently, one could speculate that they might have been more receptive of medication and more open-minded in their help-seeking behaviors. Nevertheless, the interviewees also valued the stabilization-focused group psychotherapy as an adjacent offer. Stabilization group psychotherapy [23,24] and the self-practice of stabilizing techniques via audio-files [25] have been shown to increase mentally burdened refugees' emotional stability in the early post-migratory phase. In general, guided-imagery techniques can be a valuable resource in cross-cultural work and treating PTSD [63,64].

Difficulties in the context of therapeutic encounters can include the use of interpreters [65,66], fear of verbalizing (emotional) problems [67], and differences due to cultural differences [68]. Furthermore, doubts about the usefulness or effectiveness of psychosocial treatment have also been addressed in previous studies [58,67]. Although perceived problems matched the inhibiting factors described above, they seemed to be low in our study, where feelings of gratitude for receiving therapeutic support clearly outweighed perceptions of difficulties. Unfortunately, interculturally trained, foreign language, and specialist language qualified therapists are rare and mental health services often have to rely on interpreter services. Still, the patient's and the interpreter's cultural background as well as their fit should always be taken into account. Professional knowledge about cultures and culturally sensitive communication are key in efforts toward bridging cultural barriers in healthcare. Hence, culturally sensitive communication training programs should be established. Regarding the high levels of noise in the waiting area, a respondent advised putting up "Please be quiet" signs, which could prove to be a simple solution to a big problem. However, as the clinic location is in former military barracks, which were by no means originally built for medical and psychosocial care, these structural barriers will be difficult to solve and reflect the difficult accommodation situation that refugees face in the PHV. In addition, it must be noted that questions about critical aspects or suggestions for improvement often remained unanswered or received evasive answers.

With regard to the pursuit of follow-up treatment outside of the PHV, most patients felt motivated to reach out to psychosocial services after municipal accommodation. Nonetheless, some patients hoped that their mental health would improve as post-migratory stressors subsided and felt they would not need further help. In line with previous findings [56,59,60,69], our sample cited shame, fear of stigmatization, lack of time, symptomrelated difficulties, and lack of information as barriers. Overall, patients were optimistic about their post-reception center treatment access possibilities to therapeutic care. However, despite the refugees' belief in the availability of psychosocial care structures, there is still a great shortage of psychosocial care services in reality [16,17]. While the psychosocial walkin clinic within the center is undoubtedly an important service, such offers are regrettably rare. Rehabilitation centers for refugees and survivors of torture as well as relief organizations play an important role in later mental healthcare for mentally burdened refugees in Germany [17]. Still, the attendees' positive experiences during therapeutic consultations in the walk-in clinic may help refugees later when seeking further psychosocial support. Strengthening the interconnections between the diverse actors involved in the psychosocial

care of refugees is essential to ensuring that transitions to further direly needed treatment are successful. Patients attending the psychosocial walk-in clinic receive a medical report which includes information about their reason for attendance, symptoms assessed during the counseling session, clinical diagnoses, medication prescriptions, and further healthcare referrals. This can provide future healthcare professionals with an impression and guidance as to how to proceed. Unfortunately, interconnections between the psychosocial walk-in clinic and local professionals are still limited. Furthermore, as refugees are often relocated all over the country after leaving the intimal reception center, a nationwide network needs to be established.
