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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How tutor groups are trying to bridge the inequality gap in Swedish schools

In Sweden, every fourth student in compulsory education has a foreign background, which means that they were either born abroad or born in Sweden with both parents from abroad. However, students from Swedish families and their peers with foreign backgrounds are meeting less and less often in schools, in a result of increased segregation that is posing a challenge for many municipalities.

How tutor groups are trying to bridge the inequality gap in Swedish schools
Camilla Wennberg and Zamzam, one of her students. Photo: Private

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 2019, Sweden's public broadcaster SVT surveyed 3,641 primary schools and reviewed data from Skolverket, the Swedish National Agency for Education, on the academic year 2017/2018. The results showed that the distribution of students from foreign backgrounds was very unequal, with some schools having almost only students from migrant families and others having as few as five percent. According to Skolverket, the concentration of students with the same social and migration background might be one of the reasons for an increased difference in school results, which poses a threat to the goal of offering equal opportunities for all.

The relation between segregation and difficulties in succeeding in school was pointed out by some of the migrant parents in study circles that Eva Lundgren Stenbom, a cultural producer, organised in Norrköping, central Sweden, in 2013. The very decision to found her own NGO, Imagine (what we can do), was motivated by an encounter with the mother of a girl who participated in a project Eva Stenbom worked previously. She wanted help to get to know more locals with whom she could practise her Swedish, because Eva was in fact the only Swede she talked to regularly.

Seeing how difficult it could be for a foreigner to establish relations and feel part of society, Lundgren Stenbom created the association and started the study circles, among other activities such as sewing workshops. The events were planned for locals and migrants living in neighboring areas of the city to meet once a week and discuss the everyday issues they faced in their community.

The meetings were attended mostly by adults, sometimes followed by their children. Topics on integrating into Swedish society and parenthood would often come up, and Lundgren Stenbom remembers many parents asking for help with problems that affected their children, especially in school. Thinking about the younger generations and hearing the demand from parents, she decided to expand the study circles to include children.

For the past four years, an increasing number of students with migrant background have enrolled on the tutoring programme organised by Imagine (what we can do). At first, the study circles took place in Lundgren Stenbom's home, located in a neighbourhood that is almost the perfect metaphor for the segregation between locals and migrants. On one side of the street is the Röda Stan neighbourhood, where most of the houses are owned by Swedes, while right across Värmlandsgatan many migrant families live in the Marielund buildings. The organisation started with the aim of creating places and opportunities for the neighbours to meet.

However, the study circles soon showed to be inefficient, Lundgren Stenbom says, because of the busy and loud atmosphere of several students sharing the attention of few tutors. “Sometimes there would be 10 or 12 students for two or three tutors, and it made it very difficult to advance in the lessons,” she remembers. A different system was needed.

The tutoring programme then became individualised, with better results, according to the NGO's evaluation. As it currently works, each student is paired with a tutor with whom they will work for at least one semester. The meetings usually take place at the tutor's house, which proved to be the best solution and one of the learnings the organisation had throughout the years. “Because many of the students live in families with more kids, very often it is more difficult for the student to focus and concentrate on the work without interruption,” Lundgren Stenbom explains.

The programme also recommends that the tutor/student pair set a schedule of weekly meetings on a pre-defined day and a time slot of one to two hours. Feedback and follow-ups are constant, but according to Lundgren Stenbom they lack data on how much the students' grades have improved after enrolling in the programme.

There are currently 35 pupils, mostly aged 11 to 19 years, receiving help with homework or preparing for exams, and another 20 people on the waiting list. Several of them have been in Sweden for almost 15 years, while some have moved to the country more recently. The goal, Lundgren Stenbom states, is to support the students so they progress to higher educational levels and get better opportunities on the job market.

One of the volunteers on the programme is Camilla Wennberg, an engineer who has tutored two students since 2017. Her current pupil is 14-year-old Somayo, from Somalia, with whom Wennberg has worked for the past one-and-a-half years. Before that, she taught Somayo's older sister Zamzam for two years.

Before stricter recommendations to lower the spread of the coronavirus came into effect in Sweden, every Wednesday evening Somayo and one of her parents would cross Norrköping by tram to go to Wennberg's house. The father or the mother accompanied her because they believe taking the tram alone at night is not safe, which Wennberg agrees with. During the weeks when social contact has been more restricted, tutor and student have met online.

The effort that Somayo and her family make to attend the tutoring session and the fact that she has been not only up to date with her homework, but a bit ahead of the class, is a sign for Wennberg that the Somalian teenager has high educational aspirations. “She is more ambitious,” states the proud tutor. 

Wennberg sees the language as a main factor for difficulties children from migrant backgrounds may have in school. “When it's just calculation it's easy, but when you have to understand what the question is asking for, then it is more complicated for her.” Sometimes they translate the questions to English, which helps.

Ann-Sofi Ringkvist and Madeleine Szente, who coordinate a programme by the Red Cross, which has provided support to schools in Linköping since 2011, also believe that improving language skills is an important feature of homework tutoring and one of the biggest challenges for migrant students and their families in the integration to the school system.

Although the programme was not created with the purpose of helping children from migrant backgrounds, but everyone who needs extra educational support, most of the students are currently from migrant families.

The three schools where the Red Cross is present in the city show the divide in the distribution of students with different backgrounds: in the Skäggetorp neighbourhood, the vast majority of students in the two schools participating in the programme belong to migrant families, while in Ekholmen the proportion of students who do not have a Swedish background is much smaller: around five per class. Ringkvist, who is herself a volunteer, believes that children benefit from a mixed class environment and stresses that several students need tutoring, independently of their family's country of origin.

The program is aimed at students from 8 to 16 years of age. In grades seven to nine, the tutoring takes place after school, while for younger pupils it takes place in a separate room during school time. Unlike the initiative in Norrköping, where the tutoring is requested by the families, the Red Cross volunteers collaborate with the school staff. The tutors, many of whom are retired teachers themselves, work with groups of students and follow the instructions from the teachers. During the sessions, two volunteers provide support for groups of 10 to 15 pupils, but there are times when as many as 25 young students are working together.

The large number of people attending tutoring sessions is seen by the organisation as both a challenge and a sign of success. Ringkvist explains that students wanting to receive tutoring is understood as a positive evaluation of the volunteer's work, but that many children in the same room can make it difficult for them to focus on school content.

“There are several goals, the main one is to make going to school pleasurable. We are not supposed to give them grades, we just want to help them, so maybe they find it easier to talk to a volunteer than to the teachers.They can feel more confident of themselves,” says Szente.


Although the adults involved in the homework tutoring programmes see language acquisition as one of the main challenges students with migrant background face in succeeding in the Swedish school system, what do the young students themselves think?

Somayo, who is being tutored by Camilla Wennberg, was unavailable to be interviewed because she was taking part in a two-week introductory programme to the job market and was working part-time in a fast-food chain. Due to her busy schedule, she was not able to attend the tutoring sessions when we spoke to Wennberg.

Somayo's absence did not seem to be a matter of concern, as her tutor stressed how important the work-training programme was for the teenager. Somayo's grades and accomplishments in maths can be understood as a sign of the programme's success, and alongside the fact that she was also doing part-time work, it can be inferred that her Swedish language skills might be much higher than it may seem.

One important aspect to consider, however, is the difference between the academic language skills required to pass exams such as the national high-school exam – usually a source of anxiety for young people, as it defines the educational pathway they are able to take – and the skills required for everyday interactions in informal settings or in lower-paid work.

The unequal representation of students from migrant families in Swedish schools may result in a daily experience of segregation for the young people who are trying to navigate a school system and a culture foreign to their parents. While governmental strategies to distribute students more evenly are being developed, volunteers in the homework tutoring programmes have been making individual efforts to orientate school children.

As Camilla Wennberg describes, her encounters with Somayo and her family are limited to the tutoring sessions, but these are occasions for her to answer questions from Somayo that go beyond mathematics. She thinks of their friendly exchange with her students as an opportunity she would not have had otherwise, something she values.

“It is nice to know her,” says Wennberg. “I think most people can help others teaching their own language, for example by correcting an essay. They just need to be open minded: whatever you can give, it is worth something.”

Myung Hwa Baldini is a journalist working in education and children's rights. She is based in Sweden.