The Unit of Liaison Psychiatry at EVAM (Etablissement Vaudoise d’Accueil des Migrants), a centre for people applying for asylum, originated from a project initiated by Fondation de Nant—in the East Sector—and the Psychology of Immigration Unit of the Department of Psychiatry at the Lausanne University Hospital (DP-CHUV, from the initials in French)—in the Centre Sector. Its aim is to facilitate access to psychiatric care in asylum seekers centres EVAM.

Xavier Sanchis Zozaya, Doctor in Charge of the Transcultural Psychiatry Unit at Fondation de Nant, received us to talk about the mission of this project he is leading. “Switzerland takes in people who are, or have been in the past, persecuted for religious, ethnic or political reasons, as well as war refugees. Clinical evidence shows that these people, children and adults both, are at higher risk of suffering from PTSD, depression or anxiety, among other disorders, and the lack of early treatment and access to specialised care can have negative consequences.”

Fondation de Nant, through the Transcultural Psychiatry Unit, and the DP-CHUV received Government budget to develop their project. Dr Sanchis explained us the rest.

Once you had the green light, how did you decide to carry out the construction of a project together?

At first, we wondered about building a simple liaison service, that is to say, a service in which the psychiatrist in charge of the asylum seekers would move whenever the centre requested it, without an on-site office. It didn’t take us long, however, to realize that we needed to be a constant presence the centre.

What made you change your mind?

In order to answer this question it is necessary to understand the distribution and the function of the different centres and institutions involved. In the East Sector there are three reception centres: Vevey, Leysin and Bex. The first two are specialized in asylum seekers that have been in Switzerland for some time, sometimes they find themselves at the end of the process–before expulsion–and have often followed or follow psychiatric treatment. However, the Bex centre is the biggest one and is one of the gateways to the Canton of Vaud for asylum seekers. People living there have just arrived, haven’t had contact with psychiatry and might have psychological disorders not treated nor diagnosed. We thought it was essential to be physically present in order to intervene in collaboration with the CSI-PMU (Centre Santé Infirmier de la Policlinique Médicale Universitaire de Lausanne), our main clinical partner. It must be considered the need to work in coordination regarding social and administrative issues that we carry out together with the centre EVAM, which has a team of social workers.

On the other hand, to me it was essential to be present in order to create a team dynamic that was build daily and that enabled a more reactive work, which would ensure a better diagnosis.

Integrating in another space has its own process. How did they receive you at the centre?

In my view, the project had an enormous potential in terms of improvement of care quality for users, with a full somatic, psychiatric and social integration, but there were also risks to consider. I thought it was important to approach the issue with the CSI-PMU and EVAM, and for this reason I wanted to know exactly which were their expectations as well as their fears. This way, I presented them a work document with my ideas based on my knowledge and my experiences, I gave them time to study it and afterwards we met several times to organize it.

Which were their expectations and fears?

Given that we had already worked together in difficult cases and that they were aware of the need for psychiatric care in their centre, the opportunities this collaboration offered were clear. What was more interesting was that their fears were economic and administrative, which I didn’t expect despite that, obviously, these are subjects that must be addressed. On the one hand, the economic issue is inevitable for these projects or when several institutions work together. So, I met with the deputy director of the PMU to address very precise issues and several administrative aspects concerning the integration of our team. These meetings allowed me to understand their needs better, as well as the importance of the role that the nurses have in this project. It is important not to forget that they have an essential function: they take care of the first somatic assessment of the patients, the vaccination control and the monitoring. They work on the front-line and this must be their place in the project. From those conversations we started organizing ourselves by establishing a very good communication between us, and, on our part, raising awareness with the nurses in order to improve the detection of psychological problems.

Once the administrative issues were settled, how did the asylum seekers receive you?

I would like to insist on the need for our presence to be a constant in those centres, also for the patients. To most of them psychiatry is taboo, it’s common to think that “only crazy people need psychiatrists.” We need to be realistic, we cannot expect to set a practice and just wait for people to come. What we did was a local integration, but it requires a culture of integration and that takes time. Being in the centre, the nurse can introduce us to patients and that gives us a chance to help them. This 5 minutes we have with them make this first contact more natural, so that they do not see us as negatively.

Patients come from different countries, with different cultures and different ways to express suffering, does that impact the way care is delivered?

This means that we need to work collaboratively with several actors. In the first stages it is really important to work closely with nurses, as psychologic symptoms are not expressed the same way in every culture. Sometimes instead of expressing emotions and saying “I’m sad”, people might express a somatic complaint, like “I have a headache,” or might be afraid some spirit has possessed them… This is why the patient who has a headache will go to the doctor instead of the psychiatrist, but also why the latter needs to work closely with the former. As a psychiatrist, my work is to make the physical complaints the nurse receives into emotions, something I can talk about with the patient.

And once you have established this bond with the patient, how do you proceed?

We first need to see where we are culturally. As I was saying before, psychiatry is still a taboo—even in our society! That’s why I start every visit by asking “what do you think of psychiatry?” Then I explain to them that they can visit their psychiatrist if they have anxiety, are sad, or suffer from sleep disorders—and I always insist on the latter, as people usually associate it with physical medicine and many of the people in these centres suffer from them. In other words, I try to make them feel comfortable with what they feel, and start our conversation from there. You could say that I first start with broad issues and related symptoms, and then I move towards the main issues and symptoms. It demands a lot of patience, and you need to know how to respect the patient’s speed when treating with difficult emotions.

What is usually their reaction?

Most patients react very well, although many have never visited a psychiatrist before and don’t know what to talk about, they become quite passive, so as a psychiatrist you have to be more proactive. Despite this, I think we’ve been well received, especially from the moment that you take an interest and ask them about what they think about psychiatry. What is more complex is the fact that they are not used to sharing private and intimate experiences, as in many cultures people would never talk about those kinds of things with strangers. To accomplish this I need to make them understand that I’ll need to ask questions in order to help. It is essential that they feel they can trust me, so we can share a therapeutic bond in which they feel comfortable. This is also why I have implanted a clinical model for evaluation and orientation based in 4 appointments—you need time to stablish a bond.

You have talked before about being other professionals involved in the care process or helping the patient manage all these cultural issues, you have mentioned nurses, what are the others?

There is always a social worker. Most of our patients have lived through difficult migration processes and their psychological symptoms are translated into the body, so they might need for asylum professionals to legal-administrative appointments, or someone to write a report for their residence permit, etc. It is very important for the patient to express all their needs. And that they feel heard! If the patient believes their problem to be related to their physical health, or to bureaucracy, they won’t understand why they’re put into contact with a psychiatrist—but they need this psychic space to let their emotions surface.

Finally, there is also the interpreter, which serves also as a cultural mediator and facilitates the conversation with the patients. The interpreter’s task is subtle but fascinating, it’s very complex, and I would need an entire article to describe it well.

Let’s talk about therapy. The patients staying in these centres are in the middle of the process and they can be transferred to other centres. How do you make sure their treatment continues?

That is true, they can circulate around the Canton, and Psychiatry is not centralised by Cantons. However, the CSI-PMU is established Cantonally. To solve this we need to have a report made for the CSI-PMU for each patient, in case the Cantonal administration decides to transfer them. The CSI-PMU gathers all the patients’ clinical information and sends the report to the Psychiatric Service at the other sector. This way we can follow the patient, and we also provide specific information about each of them so they don’t have to start from zero. The main challenge when a treatment is decided is that it might need to be very short, which is why it is so important to diagnose early. We would like to work even more collaboratively with the Administration, so that they can facilitate us information about displacements and we can coordinate better and improve patient care.

Which have been your first impressions?

I work with a great team, a team of nurses who are very receptive and are very much aware of the psychiatric aspect of these centres’ patients. We aim to perfect the indications for diagnose and avoid falling into the trap o “psychiatrising” too much. We might put everybody who suffers under “psychiatric issues”, but some fears or anxieties are not pathological, they are just human suffering. Coordination is an element we cannot forget, and we have divided it into two: field coordination and directives coordination, the latter based on regular meetings where we discuss the problems we’ve found in the former. The aim of these meetings was to introduce the culture of error analysis or error management. We are currently three organisations working together, we must identify each mistake, see it for what it is, so we can learn from it.

And after this first very-hopeful experience new connections have appeared. For example, I’ve just recently integrated the Réseau Santé Migrants (RESAMI) to the Canton ambit, as a Psychiatrist. It’s only the first experience, as until now its only members were CSI-PMU, EVAM and clinical, intern and paediatric doctors—but no Psychiatrists. I believe that this collaborative work, which centres on patients and field-teams, will bring many improvements.

Thank you for your time, Dr Sanchis.

Thank you.