No cure for the minds of victims of torture and war

Half of all refugees are suffering from mental disorders as a consequence of the violence they’ve experienced. Only few of them find help.

The outpatient clinic for victims of war and torture at the University Hospital Zurich is one of the places where they can find help. It accepts and treats 150 new patients every year. The clinic also develops new, evidence-based therapeutic approaches that are adapted to the needs of their patients. We speak with Ulrich Schnyder, the clinic’s founder and head of the hospital’s department of psychiatry and psychotherapy. 

Learn more about the clinic’s work in Schnyder’s project on ResearchGate.

ResearchGate: How do your patients find you?

Ulrich Schnyder: It takes patients eight years on average after their arrival in Switzerland to find us. There are many reasons why it takes them so long. First of all, the patient doesn’t see himself as a patient. He sees himself, e.g., as a war hero, who was sent to jail and tortured for his political convictions. He usually doesn’t speak the language and often suffers from insomnia and physical pain as the consequence of torture. In Switzerland, he lives in a center for asylum seekers before he is assigned regular housing and finds a family physician. He tells the physician about his pain and the physician prescribes a painkiller or sleeping pills. The GP doesn’t realize that his patient is suffering from symptoms of psychological trauma. Even if the patient does get psychiatric help, he often can’t make himself heard, because no one speaks his language and there’s no one who’d cover the cost for a translator.

ResearchGate: Where do your patients come from?

Schnyder: Half of all people we work with currently are Kurds from Turkey. Our other patients come from all around the world, including Eritrea, Ethiopia, Iran, Iraq, Sri Lanka and Pakistan. We don’t have any patients from Syria yet because it takes patients so long to find us.

ResearchGate: What happens when patients finally find you?

Schnyder: When patients finally come to the clinic they want all kinds of different things. They don’t come to us and say they have posttraumatic stress disorder and would like to undergo trauma focused psychotherapy. No, they come and say that everything in their life is bad. They can’t sleep, they can’t talk with anyone because they don’t speak the language and there are fights at home because they have outbursts of anger. Or they’re out of money because they don’t have work and there are problems with the authorities.


"Their psychiatric disorders usually aren’t their most pressing concerns."

We spend more than 200,000 Swiss Franks a year on translators for more than 20 languages. When our patients come to us they feel like they can speak with someone for the first time since their arrival, someone who understands the complexity of their problems and can solve them. We can’t do that of course. We can’t do much about their legal, financial or administrative issues. We can offer psychiatric care and psychotherapy. We have, however, started working with the authorities because the patients’ problems are so intertwined. If someone in the German speaking part of Switzerland doesn’t speak German, they won’t find a job. If they don’t find a job, they’re less likely to learn German. If they don’t learn German, they can’t integrate into society. If they don’t integrate, they’re isolated, which can cause depression. It is a vicious cycle.

RG: What does trauma therapy look like in your clinic?

Schnyder: Trauma therapy usually involves two elements. One element is exposure therapy. The therapist guides the patient back into the traumatic situation in his imagination and makes him relive the feelings of helplessness, fear, shame, disgust, aggression, or whatever else pained him. It’s the exact opposite of what the patient wants primarily because he doesn’t want to remember these traumatic memories. One of the symptoms of PTSD, however, are sudden, involuntary flashbacks that can be triggered by all kinds of things. They could for instance be seeing a uniformed person on the street and this brings back memories of investigative authorities in Turkey. These flashbacks are so cruel that the patient does not want them to happen. In the therapy session, these flashbacks are brought about in a safe environment. After a time, the patient habituates to his painful memories and the flashbacks eventually subside.

The second element is cognitive restructuring. For instance, if a woman has been raped she might come to the conclusion that all men are dangerous and potential rapists. The therapist challenges the patient’s view, for instance by asking the patient if she knows of any exceptions. The patient then may realize that she was over-generalizing and that in fact not all men are rapists.

RG: What are challenges you face in these therapy sessions?

Schnyder: We notice all political shifts that happen in Turkey without delay. To say it bluntly, every time president Erdogan says something disturbing about the Kurds, the whole community is in rage and our trauma therapy sessions are interrupted for weeks on end.


"It’s already a lot if we do just that."

It takes long to finish this type of work. You may notice, I intentionally don’t speak of a cure. These people are so severely impaired, there is no cure. We can make a modest contribution to their wellbeing in order for them to better function in the here and now. It’s already a lot if we do just that.

RG: In addition to working with patients, you also conduct research. What are your research objectives?

Schnyder: We’re developing evidence-based therapies for victims of torture and war. For example, we’re currently working on developing a mini-intervention, an intervention focusing not on a mental disorder such as PTSD, but rather on a specific problem independent of the diagnosis. One example would be the loss of control people experience during torture. That’s a critically traumatic experience: something’s happening to them they have no influence over. They’re completely at the mercy of someone else. That strengthens the feeling of being unable to exert influence over things in their lives. We want to develop interventions that facilitate a returned sense of self-efficacy.

For this purpose, we conducted an experiment with a group of 40 patients. We divided the patients into two groups. One group was asked to complete a complex task after having imagined a situation in which they were successful. This gave them a feeling of self-efficacy. The other group was asked to imagine something unrelated to self-efficacy and then perform the same complex task. Those participants who had been thinking of their successful experiences, were more successful in solving the problem we’d given them. This encouraged us to incorporate this as an element of therapy. This project is still in progress though.

Ideally, an intervention shouldn’t be language-dependent. To that end, we’ve developed some software. Patients are shown instructions on a tablet computer. We’ve also had the instructions read aloud in various languages so that the software can also be used by illiterate patients.

RG: What does your work mean for refugees who aren’t fortunate enough to be under your care?

Schnyder: One approach I find quite interesting is that of Richard Bryant. He has developed “Problem Management Plus” (PM+). It’s five therapy sessions in which patients learn problem solving and stress management techniques that they can then teach other refugees. It’s an attempt to quickly deliver psychosocial support to a large number of people.


"We shouldn’t think it’s beneath us to explore easy solutions that can be implemented by lay people."

Last week, a Horzion 2020 research program we’re participating in was approved. It will involve applying PM+ in various populations. Richard Bryant will be working with children in a refugee camp in Jordan, another group is working with refugees on the Turkish-Syrian border, we’ll be trying it with Syrian refugees in Switzerland. We shouldn’t think it’s beneath us to explore easy solutions that can be implemented by lay people.

We’re sitting here in Zurich, have a good income, and treat 150 people a year. That’s all well and good, but there are hundreds of thousands of people who need help. A million refugees came to Europe in the last year. Worldwide, 60 million people are fleeing their homes. It’s not realistic to think all these people can be provided with individual psychotherapy. We have to take a global perspective and ask ourselves what we can do for these people.


Read more about treating victims of war and torture by Ulrich Schnyder: 
















Feature image: UNHCR Photo Unit