"It is worth hanging in there" - Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany.

BACKGROUND: A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists' motivation and facilities to accept refugee clients. A model project called "Fearless" trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists' motivation and engagement in future treatment of refugees. METHODS: From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists' experience of challenges, enrichments, and motivation throughout the therapy. Therapists' responses were analyzed using content structuring qualitative content analysis. RESULTS: Three major challenges modulated therapists' future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients' motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10). CONCLUSION: Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists' motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists' motivation to work with refugee clients.

The neural dynamics of deficient memory control in heavily traumatized refugees.

Victims of war, torture and natural catastrophes are prone to develop posttraumatic stress disorder (PTSD). These individuals experience the recurrent, involuntary intrusion of traumatic memories. What neurocognitive mechanisms are driving this memory disorder? Here we show that PTSD symptoms in heavily traumatized refugees are related to deficits in the effective control of memory retrieval. In a think/no-think task, PTSD patients were unable to forget memories that they had previously tried to suppress when compared to control participants with the same trauma history but without PTSD. Deficits in voluntary forgetting were clinically relevant since they correlated with memory intrusions in everyday life. Magnetoencephalography (MEG) recorded during suppression attempts revealed that PTSD patients were unable to downregulate signatures of sensory long-term memory traces in the gamma frequency band (70-120 Hz). Thus, our data suggest that the inability to suppress unwanted memories through modulation of gamma activity is related to PTSD symptom severity.