Psychotherapy Research

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tpsr20

Psychotherapy with refugees—Supportive and

hindering elements

Gesa Solveig Duden & Lucienne Martins-Borges

To cite this article: Gesa Solveig Duden & Lucienne Martins-Borges (2020): Psychotherapy with
refugees—Supportive and hindering elements, Psychotherapy Research

To link to this article: https://doi.org/10.1080/10503307.2020.1820596

Published online: 17 Sep 2020.

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Psychotherapy Research, 2020
https://doi.org/10.1080/10503307.2020.1820596

EMPIRICAL PAPER

Psychotherapy with refugees—Supportive and hindering elements

1,3
GESA SOLVEIG DUDEN & LUCIENNE MARTINS-BORGES2,3
1
Department of Psychology, University of Osnabrück, Osnabrück, Germany; 2École de travail social et de criminology, Faculté
des sciences sociales, Université Laval, Québec, Canada & 3Departamento de Psicologia, Universidade Federal de Santa
Catarina, Trindade, Florianópolis, Brazil
(Received 17 February 2020; revised 1 September 2020; accepted 1 September 2020)

Abstract
Globally, nearly 80 million people are forcibly displaced. Being a refugee can impact one’s mental health profoundly.
Although specific approaches for psychotherapy with refugees have been developed, this study is the first to investigate
psychotherapy with refugees in Brazil. Semi-structured interviews were conducted with 18 psychotherapists in Brazil and
analysed using consensual qualitative research and thematic analysis. Supportive and hindering elements in psychotherapy
with refugee patients in Brazil were identified at eight different levels: the patient, the therapist, their relationship, the
setting, the psychotherapeutic approach, the context of the patient, the context of the therapist and the societal context in
Brazil. Hindering elements in the therapy include missing preparation for the integration of refugees, lack of interpreters,
patients’ mistrust and therapists feeling untrained, helpless and becoming overinvolved. Supportive elements include a
trusting therapeutic relationship, therapists’ cultural humility and structural competence, patients’ societal inclusion as
well as working with groups and networks. This study shows that in light of the enormous structural challenges for the
mental wellbeing of refugee patients, therapists’ flexibility and the reliance on collective work and networks of support is
crucial. Future research might investigate in more detail notions of collectivity-based mental healthcare in intercultural
therapy settings.

Keywords: Transcultural Psychotherapy; Refugees’ Mental Health; Brazilian Healthcare; Migration; Providers’
Perspectives; Qualitative Research

Clinical or methodological significance of this article: This is the first study of its kind investigating psychotherapy with
refugees in Brazil and providing insights into what psychotherapists experience as supportive and hindering in their work. The
results highlight the importance of adaptability and structural competence of psychotherapists, a move from knowledge-based
cultural-competence concepts towards more flexible notions such as cultural humility and the usefulness of collectivity-based
work strategies such as networks, co-therapy, teamwork and group therapy. Furthermore, collectivity-based strategies could
help to counteract the feelings of helplessness in therapists, which, as this study suggests, might stem from contextual
struggles, such as lack of funding and unmet basic needs of patients, and which are, in the case of Brazil, reinforced by the
precariousness of the ongoing social, economic and political insecurity.

Historically, psychology has relied on theories and
data derived from a specific and small part of the
world’s population, namely Euro-North-Americans
(Hartmann et al., 2013; Parra, 2013; Wampold &
Imel, 2015). However, culture influences construc-
tions of pathology, as well as forms of healing (Kir-
mayer, 2004). Investigations of the concepts of
diagnosis, psychotherapeutic treatment approaches
and settings in a greater variety of cultures and
countries are needed (Duden et al., 2020; Parra,
2013). The present study focuses on psychotherapy
in Brazil and specifically on the treatment of refugee
patients.
Since its re-democratisation, Brazil has become a
country of resettlement with specific laws for refugees
(Jubilut, 2006). However, little is known internation-
ally about refugees in Brazil and especially about their
mental healthcare (Teixeira et al., 2013). The

Correspondence concerning this article should be addressed to Gesa Solveig Duden, Department of Psychology, University of Osnabrück,
Neuer Graben, 49074 Osnabrück, Germany; Departamento de Psicologia, Universidade Federal de Santa Catarina, Campus Universitário,
Trindade, Florianópolis, SC CEP: 88040-500, Brazil. Email: g.duden@zoho.com

© 2020 Society for Psychotherapy Research

2 G. S. Duden and L. Martins-Borges
national Brazilian healthcare system (SUS), estab-
lished in 1988, aims to provide comprehensive, uni-
versal healthcare free of charge (Loch et al., 2016;
Paim et al., 2011). It is based on an ample under-
standing of health, incorporating physical, socioeco-
nomic and cultural factors. Brazilian law states the
right of access to the SUS for everyone, without any
discrimination (Böing et al., 2009), thus including
refugees. Brazilian mental health policy, being
strongly influenced by the democratic psychiatry
movement in Italy (Goulart & González Rey, 2016),
emphasizes a model of family- and community-care
(Marsillac et al., 2018). Psychosocial care centres
(CAPS), inaugurated as alternatives to traditional
asylums, form the cornerstone of Brazilian mental
healthcare (Goulart & González Rey, 2016). These
centres entail multi-professional teams which
support people with mental health problems by allo-
cating resources within the community, such as
through home visits and community activities, as
well as by offering therapeutic care adapted to each
patient (e.g. family and group therapy, individual psy-
chotherapy, work-related workshops). All of these
services are offered free of charge and can be one-
time or of long-term duration (Goulart & González
Rey, 2016).
The creation of the SUS has certainly improved the
access to (mental) healthcare in Brazil. However,
problems remain: units are fragmented, poorly inter-
linked and overly bureaucratic (Böing et al., 2009),
coverage is distributed unequally due to limited gov-
ernmental spending on mental healthcare (Doniec
et al., 2018; Marsillac et al., 2018) and there is a
lack of specialized services for refugees (Bógus &
Rodrigues, 2011). The demand for the latter, as
well as more information on the needs of refugees
in Brazil has increased dramatically, in particular
with the humanitarian crises in Venezuela from
2016 onwards (CONARE, 2019). The few mental
healthcare services which are specialized in treating
refugees are usually offered by volunteers, by non-
governmental organizations (NGOs), or as part of
“community-outreach”-projects of universities
(Jubilut, 2020).
Refugees form a very heterogenous group;
however, they are often placed into a single category
due to the commonality of their predicament. Cer-
tainly, not all refugees develop mental health pro-
blems, but higher rates of mental disorders and
psychological symptoms compared to the general
populations in host countries seem common follow-
ing the experiences of violence, war, displacement
and difficulties in resettlement (Carswell et al.,
2011; Fazel et al., 2005). Reports have shown elev-
ated rates of anxiety and depression, as well as a
high prevalence of post-traumatic stress disorder
(PTSD) – sometimes registered to be up to 10
times higher than in the general population (Fazel
et al., 2005; Lindert et al., 2009). In the Brazilian
context, a study of Haitian immigrants in Southern
Brazil yielded a PTSD prevalence rate of 9.1% and
found that depression and anxiety symptoms were
in the clinical range in 10.6% and 13.6% of partici-
pants respectively (Brunnet et al., 2018). However,
this study remains one of the very few investigations
on immigrant and refugee mental health in Brazil,
and a lack of research and data in this area persists
(Moraes Weintraub, 2012; Teixeira et al., 2013).
Internationally, studies investigating diverse facets
of psychotherapy with refugees have increased (Bar-
rington & Shakespeare-Finch, 2013; Duden et al.,
2020). For instance, Björn et al. (2013) used
content analysis of videotaped therapy sessions with
refugee families to determine that professionals who
possessed an awareness of the sort of lives refugees
had lived before their flight to a new country were
able to better accommodate patients’ needs. Other
studies found that establishing a trusting relationship
with refugees is a priority and challenge in the therapy
and might take a long time, as negative past experi-
ences, unfamiliarity with the host country’s health-
care system, negative preconceptions of
psychotherapy, and hostile attitudes of receiving
communities seem to be major barriers for the devel-
opment of trust (Codrington et al., 2011; Sandhu
et al., 2013). Furthermore, the therapeutic relation-
ship is influenced by the presence of interpreters
who are often considered indispensable when
working with refugee patients (Codrington et al.,
2011; Mirdal et al., 2012; Puvimanasinghe et al.,
2015). Miller et al. (2005) observed, for example,
that interpreters had an impact on the therapeutic
alliance as well as on complex emotional reactions
within the therapy triad, which are exemplified by
therapists feeling excluded from the bond forming
between interpreters and patients.
Further investigations on psychotherapy with refu-
gees have focused on aspects such as trauma therapy.
Some have found that the witnessing and validating
of traumatic experiences by an outsider can play an
important role in a healing process (Griffiths,
2001). This idea forms the base of the testimony
therapy approach with refugees (Lustig et al.,
2004). The necessity of refugees “talking through”
their traumatic memories, however, remains a
debated issue (Shearing et al., 2011). For instance,
Savic et al. (2016) found that among Sudanese refu-
gees in Australia many preferred “getting on with
life” rather than talking about psychological pro-
blems. Vincent et al. (2013) observed ambivalences
about engaging in trauma-focused cognitive-behav-
iour therapy among asylum-seeker patients,

especially when the asylum-seekers were living in fear
of repatriation.
Additionally, two current metasyntheses of quali-
tative studies investigating psychotherapy with
refugee patients (Duden et al., 2020; Karageorge
et al., 2017) underscored the importance of two
major aspects: Firstly, they emphasized the huge
impact this type of work can have on professionals.
Factors such as patients’ ongoing contextual instabil-
ity influence professionals emotionally and can lead
to changes in professional identity, as has also been
reported by other studies (e.g. Apostolidou, 2015;
Barrington & Shakespeare-Finch, 2013; Puvimana-
singhe et al., 2015). Secondly, the metasyntheses
highlighted the benefit of adapting therapeutic
methods to patients. This finding is supported by lit-
erature concerned with refugee patients, but also with
patients from the general population (Savic et al.,
2016; Wampold & Imel, 2015). Adapting methods
and addressing refugees’ complex needs through
advocacy, psycho-social as well as interdisciplinary
work has shown especially helpful in the eyes of
patients and staff (Codrington et al., 2011; Watters,
2001). For instance, Al-Roubaiy et al. (2017)
reported that there was a strong whish among Iraqi
refugees in Sweden that therapists recognize and
address their exile-related stressors, which they per-
ceived as the foremost reason for seeking psychother-
apy. The two metasyntheses also observed
professionals’ cultural humility (Kirmayer, 2012;
Tervalon & Murray-Garcia, 1998), as well as their
structural competence, i.e. an awareness of the
socio-political context of patients (Metzl & Hansen,
2014) to be central to a positive experience of
mental health support.
Certainly, the literature about psychotherapy with
refugees is growing; however, most of the studies
cited originate from Western Europe, North-
America and Australia. The present study aimed to
focus on the experience of psychotherapists who
work with refugee patients in the Brazilian context.
We suggest that solutions to difficulties encountered
by these psychotherapists could be a valuable
resource for psychotherapy with refugees in other
countries (Parra, 2013). In other words, such an
investigation may advance our international knowl-
edge base of transcultural psychotherapeutic treat-
ment for refugee patients and facilitate structural
and clinical support for this group. As the experiences
of psychotherapists working with refugees in Brazil
may be very complex and have yet to be investigated,
we apply qualitative methods for the understanding
of these perspectives. Specifically, we pose the ques-
tion of what psychologists who conduct psychother-
apy with refugees in Brazil perceive as supportive
and as hindering elements in their work.
Psychotherapy Research 3
Method
Study Design, Participants and Procedures
This research rests on a constructivist ontology, a
subjectivist epistemology and uses qualitative pro-
cedures of inquiry. The current article is part of a
larger study investigating the mental healthcare of
refugees in Brazil. This study specifically is con-
cerned with the experience of psychotherapists
working with refugees in Brazil. Participants were
recruited using gatekeepers and by contacting local
NGOs and subsequently via snowball sampling.
Individuals were only eligible to take part in the
study if they held a university degree in psychology.
Undergraduate degree programmes in Brazil
conform to a national curriculum and involve three
years of general studies in psychological science, fol-
lowed by two years of area-specific and practical
internships (Rezende, 2014). Advanced academic
degrees were not an inclusion criterium, but six of
the participants held masters’ degrees and four also
had a doctoral degree. For more details on psychol-
ogy curricula in Brazil please see for instance
Rezende (2014). Another inclusion criterium was
the requirement that participants had been working
psychotherapeutically with refugee patients for at
least six months. There is no formal license to prac-
tise psychotherapy in Brazil, and psychologists can
work psychotherapeutically after finishing their uni-
versity degree. Therefore, participants were asked to
self-define their work, and only participants who
declared their work to be clinical and psychothera-
peutic were included. Furthermore, all participants
of the present study were registered with a Regional
Council of Psychologists, which forms part of the
Brazilian Federal Council of Psychology and serves
as an ethics board of the psychology profession.
All participants had been educated in psychoanaly-
tic theory during their university studies except one,
who had focused on systemic therapy. Seven partici-
pants had additionally taken part in intercultural psy-
chology university courses and subsequentially
specialized in an ethnopsychoanalytic perspective
(Devereux, 1978; Martins-Borges & Pocreau, 2009)
during their practical internships. None of the partici-
pants worked in the public healthcare system with
their refugee patients. Instead, 14 participants
treated refugee patients on a volunteer basis and did
not receive any form of payment for this work.
Three participants were linked to a university which
financed their work through a community-outreach
programme (Jubilut, 2020). One participant was
financed through an international NGO. Participants
worked with refugee patients in their private prac-
tices, in spaces provided by universities, by a hospital
or by NGOs. As many participants did not keep
4 G. S. Duden and L. Martins-Borges

systematic records on their patients, no average of recorded and transcribed. Identifying information
therapy duration nor number of patients per therapist was removed and the names of the participants
can be provided here. However, in their interviews, were substituted for numbers.
participants reported seeing their patients over dur-
ations varying from three sessions only to periods of
over two years depending on patients’ needs, but Data Analysis
also on the time and financial capacities of therapists.
In line with the subjectivist epistemology of the
All participants gave their informed consent.
present study, transcripts were analysed adopting
Ethical approval was obtained from the Ethics com-
principles of consensual qualitative research (Hill
mittee of the University of Osnabrück. A total of 18
et al., 2005; Williams & Morrow, 2009) and thematic
psychotherapists were interviewed (Table I) using a
analysis (Braun et al., 2014) focusing on the explicit
semi-structured interview guideline, which had
meaning in the data. In total, three researchers were
been pilot tested to ensure the unambiguity of ques-
involved in the analysis process, a German clinical
tions. The semi-structured interviews lasted
psychologist and two Brazilian clinical psychologists.
between 40 min to 2 h and were conducted in Portu-
Firstly, every interview was read thoroughly and given
guese, face-to-face at workplaces of participants (n =
a title with its most prominent message. Additionally,
12) or via skype (n = 6). Each interview was audio
word clouds were generated to create an overview of
noticeable themes in the data. Subsequently, a data-
based analysis style was used, whereby the first
Table I. Characteristics of participants. author identified units (codes) in the transcripts and
Characteristic (n = 18) M (SD)/n range/% collated them into categories of meaning (themes
and subthemes), thus developing a coding tree (Mal-
Age, years 35.16 (11.6) 23–60 terud, 2001). This procedure was undertaken in Por-
Gender tuguese. The coding tree was re-applied to the data
Male 3 16.7 by the first author and by the two other researchers
Female 15 83.3
Experience as
independently. Researchers evaluated the fit of the
a therapist, years 10.3 (10) 1–30 coding tree, translated it into English and discussed
a therapist with refugees, years 4.4 (2.8) 1–9 the codes, subthemes, themes and translation until
City (State) of work a consensus about their structure and labels was
Boa Vista (RR) 1 5.6
reached. Subsequently, the qualitative analysis soft-
São Paulo (SP) 5 27.8
Curitiba (PR) 5 27.8 ware MAXQDA (VERBI Software, 2019) was used
Foz do Iguaçu (PR) 1 5.6 to organize the text of all interviews into the themes
Florianópolis (SC) 6 33.3 and obtain the frequencies of participants who
Country of origin talked about each theme (Table II). This quantifi-
Argentina 1 5.6
cation does not allow for inferences of statically
Brazil 13 72.2
Colombia 1 5.6 valid prevalence. It was used merely to gain an over-
Lebanon 1 5.6 view of the representation of each theme in the data
Syria 1 5.6 set, labelling themes with “general” if they applied
Uruguay 1 5.6 to 17–18 cases, “typical” if endorsed by 11–16 par-
Working with interpreters
ticipants, “variant” for less than 11 but at least three
Sporadically 2 11.1
Never 16 88.9 cases, and “rare” for one or two cases (Hill et al.,
Languages of therapy 2005).
Portuguese 18 100
Spanish 10 55.6
French 5 27.8
Author Positionality
English 4 22.2
Arabic 2 11.1 The first author is a doctoral candidate in psychology
Psychotherapeutic approach
and served as the study’s principal investigator and
Psychoanalysis 10 55.6
Ethnopsychoanalysis 7 38.9 first coder. While she grew up in a city in eastern
Systemic psychotherapy 1 5.6 Germany, her experiences and academic interests in
Work financed by migration have raised her awareness for structural
University 3 16.7 challenges in post-migration settings and the need
International NGO 1 5.6
for culturally sensitive service providers. She lived
Voluntary 14 77.8
in Brazil for several years, worked in psychotherapeu-
Note. Data are mean (standard deviation) or n and range or tic clinics for refugees in Germany and Brazil and
percentages. Percentages are rounded to one decimal place. participated in research activities in a Brazilian
 Psychotherapy Research 5
Table II. Level of analysis, themes and frequency of occurrence of each theme.

Supportive/ Frequency of Occurrence

Level Hindering Theme (#T)

Brazilian Context Hindering Inadequate preparation to receive & integrate refugees General (17)
Access to mental healthcare is difficult Typical (16)
Mental healthcare system lacks funding & communication Typical (13)
between services
Patients’ Context Hindering Basic needs not met Typical (13)
Facing prejudice, discrimination, racism Typical (14)
Bureaucratic barriers to integration Variant (10)
Instability Variant (10)
Family separation & isolation Variant (8)
Injustice & no reparation Variant (8)
Supportive Inclusion & access Typical (14)
Social contact Variant (9)
Basic needs satisfied Variant (6)
Therapists’ Context Hindering Voluntary work Variant (6)
Feeling untrained Variant (5)
Working alone & being isolated Variant (5)
Conflicts in teamwork Variant (3)
High number of cases Rare (2)
Supportive Interdisciplinary network Typical (15)
Supervision Typical (15)
Therapists’ own psychotherapy Typical (14)
Therapists’ strategies to cope Typical (13)
Teamwork Typical (12)
Education in cultural psychology Variant (9)
Patient Hindering Mistrust Variant (8)
Unfamiliarity with psychotherapy Variant (8)
Talking about suffering is hard Rare (2)
Supportive Desire to talk & engage Variant (5)
Strength & resilience Variant (4)
Therapist Hindering Getting overwhelmed Typical (15)
Ethnocentrism Variant (9)
Feelings of power & helplessness Variant (6)
Supportive Cultural decentring & humility General (17)
Contextual & political awareness General (17)
Theoretical decentring Typical (13)
Desire to attend & genuine interest Typical (13)
Self-awareness Variant (8)
Therapeutic Hindering Bonding takes longer Variant (8)
Relationship Overidentification with patient Variant (5)
Supportive Relationship as most important aspect Typical (12)
Speaking patient’s language Typical (12)
Trust Typical (11)
Being there Typical (11)
Having had similar experiences Variant (7)
Show interest in culture Variant (6)
Setting boundaries Variant (3)
Flexible understanding of the relationship Variant (3)
Setting Hindering Communication difficulties & lack of interpreters Typical (13)
Improvised space Variant (4)
Supportive Work outside of private practice Variant (10)
Co-Therapy Variant (10)
Group Therapy Varian (9)
Cultural mediator Variant (9)
Working in Portuguese Variant (7)
Use of technologies Variant (4)

(Continued)
6 G. S. Duden and L. Martins-Borges
Table II. Continued.

Supportive/ Frequency of Occurrence

Level Hindering Theme (#T)

Approach Hindering Trap of “assistancialism” & overinvolvement Typical (12)

Having to adapt traditional approach Variant (3)
Cultural camouflage Variant (3)
Supportive Truly listening & being present General (18)
Flexible & adaptive Typical (15)
Support strengths & autonomy Typical (14)
Work outside the psychotherapeutic realm Typical (14)
Non-verbal methods Variant (8)
Address meaning & identity questions Variant (7)
Long term psychotherapy Variant (7)
Working on here & now Variant (3)

university. These experiences, as well as the fact that
the co-author and the additional coder are Brazilian
clinical psychologists, increase the likelihood that
local significations and the way therapists in Brazil
speak about their work were captured adequately.
All three researchers have experience in qualitative
research methods, including interview studies and
qualitative analysis, as well as in the use of analysis
software. The authors expected psychotherapists to
highlight the Brazilian political situation as a main
challenge in their work.
Results
The analysis showed that therapists’ accounts of their
work experiences involves eight levels of description.
Figure 1 depicts these levels in an interconnected
way: The general Brazilian context (BC) provides the
all-encompassing background for the therapeutic
encounter. Within this general Brazilian context, the
therapist and patient have further contexts which are
more specific to them (e.g. their family etc., here rep-
resented as TC and PC) and which partly overlap.
One element of the context is the specific setting (S)
in which therapist and patient meet and in which the
therapy takes place, as well as the specific therapeutic
approach (A). When therapist (T) and patient (P),
each with their unique characteristics, encounter each
other in the therapeutic space, they start forming a
therapeutic relationship (R), depicted in the centre of
the figure. For each level, themes (see Table II) were
formulated. In the following section, each of the
levels with its themes will be described in more detail.
Brazilian Context (BC)
All therapists referred to the BC as a struggle for the
psychotherapy with refugees: They perceived the

Figure 1. The eight levels of analysis.


country to be unprepared to receive and integrate
refugees. Furthermore, participants typically high-
lighted the general lack of funding and communi-
cation within the mental healthcare system and the
difficulties in accessing mental healthcare for
refugees.
It was very hard to get in touch with the reality of public
policies in Brazil, the social reality. I think it becomes
very obvious and very bleak, the unpreparedness that
Brazil has to receive immigrants. So, I felt myself
hitting walls, everywhere I ran there was a wall […]
so it’s very tiring, it’s exhausting. It is even a bit sicken-
ing, working here with all the limitations and there are
limitations that are so much worse concerning the
issue of immigration, the specificities of immigrants,
of rights […] this is a challenge that escapes the very
comfortable field of psychotherapy. (07)
Patients’ Context (PC)
A typical theme concerned the unmet basic needs of
patients (food, housing) which, together with the high
legal and economic instability, led patients to have
other priorities rather than attending psychotherapy
and thus hampered regular therapeutic meetings:
“You can’t talk about the trauma because you’re
there in a very perverse reality” (02). More than
half of the therapists also described how the discrimi-
nation patients were experiencing, along with con-
stant bureaucratic and integration difficulties,
hindered progress in the psychotherapeutic process.
A variant hindering element for the therapy consisted
of the separation of patients from their families,
patients’ subsequent feelings of isolation as well as
the lack of reparation for experienced injustice.
Positive counterparts of these hindrances included
supportive factors such as basic needs being met,
increased stability, reparation for injustice and
patients’ inclusion in the Brazilian society. A variant
supportive theme was social contact to Brazilians
and to people from the patients’ country of origin.
A refugee doesn’t want others to feel pity. I’m sure he
prefers opportunity. He wants to be able to work, to
study, to be in school, he wants to be able. The
refugee comes in search of possibility. Because in
the country that he left it was impossible to live. So,
I think that’s what improves the refugee’s mental
health: Access. (05)
Therapists’ Context (TC)
Therapists stated that working on a volunteer basis
and dealing with a high number of cases limited the
time they could dedicate to each patient. It also
Psychotherapy Research 7
reduced their opportunities to exchange with other
professionals and to learn about their patients’ cul-
tures. While conflicts in teams complicated their
work, working alone was also perceived as a hindering
element, as it increased the burden and the sense of
responsibility they felt. Some therapists felt unpre-
pared and not trained for the work, especially those
whose training did not address social issues or
culture, but whose studies had rather focused on “tra-
ditional” psychotherapeutic work: “Where I studied,
it was very hegemonic. Not at all concerned with cul-
tural issues and socio-political suffering. So, all of this
was very new to me.” (16)
Before my job was […] much slower work. It was a
much deeper job. To deal with the defence mechan-
isms, to look for all that, to help people find answers.
Now you don’t have time to look for answers. You
don’t have time. People are suffering here, they’re
suffering now. What to do with this suffering in 50
min? So, it’s kind of frustrating on many levels. I
learned to do it one way and now none of what I
learned applies. (17)
Typically, being inserted in and receiving support by
interdisciplinary networks countered the feelings of
being overburdened, enabled referral and the con-
tinuous treatment of patients in collaboration with
the healthcare system and other public institutions.
Similar reasons were given for the helpfulness of
teamwork: it allowed for multiple perspectives on
cases, therapists feeling supported, and learning
from more experienced professionals.
I think the first [helpful aspect] is our team. Our
team, it’s very united, very engaged. So, you receive
a very difficult case, that usually is every case, but
there are some that are more [difficult], then you
know you will have a clinical meeting with your
team that will listen to you and we will think together
about what to do. I think that having a group of pro-
fessionals in this area helps a lot. Because then there
is always someone who will think of something. A sol-
ution emerges. (18)
Psychotherapists typically also stressed supervision,
help from their own psychotherapist, various personal
strategies (e.g. writing and sports), and university
education in cultural psychology as supportive
elements. The last factor was mainly considered to
be relevant by the participants who had studied at a
university in Brazil that offered specialized training
in ethnopsychoanalysis and intercultural psychology.
These participants felt that such training increased
their awareness about global socio-political contexts,
which in turn, prevented them from being over-
whelmed when seeing the structural challenges
facing patients. The intercultural education also
8 G. S. Duden and L. Martins-Borges
trained them in cultural humility and engaging with
cultural differences with openness and curiosity.
Patient (P)
Therapists saw patients’ mistrust as a variant hinder-
ing element. It complicated the therapy, especially at
the beginning, but was seen as understandable con-
sidering the patients’ past experiences and unfami-
liarity with psychotherapy. Patients’ difficulties in
talking about their suffering was a rare theme.
[…] especially in the very serious cases, and the most
serious ones do not even mean a psycho-diagnosis, it
is only more serious in the sense that they are more
distrustful of any human contact, sometimes with
sufficient reason. He had his whole family murdered
in front of him and he managed to escape. Or in his
country he is no longer recognised as a citizen, he is
persecuted, he has to flee. He has every reason to
be suspicious of human contact. So, the more dis-
trust they have, I think, the harder the job is. (05)
Patients’ resilience and strengths, as well as the desire
to talk about suffering and to engage in the thera-
peutic process were thematised as supportive charac-
teristics in patients:
At the end of a two-year trajectory, she is enrolled in
the university, manages to have a life project, and to
reorganise herself again. She says: ‘Look, I’ve learned
a lot from all the difficulties I’ve experienced. I ended
up being a much stronger person, who is much more
capable today of facing much more difficulty than
before, because I had to absorb all of those impacts
and work through those impacts.’ There is a particu-
larity in each story about how to relate to the trauma.
It involves the resources of each individual, social and
financial resources, specific to each subject. (14)
Therapist (T)
Of all themes, therapists’ attributes were referred to
most and by all participants. Typically, therapists
described struggling with getting overwhelmed by
continuous exposure to traumatic stories, by having
to juggle too many responsibilities and by becoming
aware of the structural causes of patients’ suffering.
Furthermore, some therapists saw feelings relating
to power and impotence as hindering: they experi-
enced powerlessness in the face of their patients’ pro-
blems, but also felt in a position of power due to the
patients’ high degree of vulnerability, and struggled
with admitting their impotence as this would de-
idealise and compromise the patients’ image of them:
They will ask for everything. Everything is always
denied. The doors are so closed, so when you open
one, the person thinks she will find everything in
there. So, it’s not easy. For us, it’s not easy too,
because you have to deal with the powerlessness.
You say: ‘I can’t offer everything.’ So, I have to
reduce expectations, de-idealise. To her, I won’t be
as potent … I will be a person who can offer some
things, but not others. (13)
Overcoming ethnocentrism was also seen as difficult,
insofar as it required becoming aware of one’s own
cultural shock and not acting on presumptions or
falling into moralizing behaviour when encountering
cultural differences.
Most comments concerned supportive character-
istics of therapists such as the importance of cultural
decentring and humility, which was in turn explicated
as becoming aware of one’s culture, decentring from
one’s own values, questioning knowledge, having a
non-judgemental, not-knowing attitude, and being
open to patients’ worldview and proper cultural ways
of healing. The theme also comprised an attitude of
respect for otherness and cultural sensibility. Secondly,
therapists found it helpful to show awareness of
patients’ political and contextual situation by studying
the geopolitical contexts of flight, and to understand
patients’ social position in Brazil and in their country
of origin. Thirdly, the importance of theoretical decen-
tring – in other words, being open-minded and not
rigid in terms of content and process of the therapy –
was typically stressed, as the work seemed rarely pre-
dictable. Fourthly, therapists typically referred to an
authentic interest in patients as well as a strong dedica-
tion to the work as essential requirements for thera-
peutic success: “ … you have to like it, you have to
believe in it and you have to dive into it, dedicate your-
self to it because it’s often not just a nice job in the
doctor’s office.” (08) Finally, some therapists stressed
self-awareness, including the awareness of their limits
and of situations that evoked their anxiety.
Relationship (R)
Various therapists described bonding with refugee
patients as difficult due to patients’ mistrust, unfami-
liarity with psychotherapy or due to cultural differ-
ences. Typically, they also saw a risk of getting
overly involved due to the patients’ high degree of
vulnerability, or of over-identifying with patients,
which would potentially lead to a dependency
relationship or hinder a not-knowing attitude.
I am challenged not to let me get carried away by my
emotions, because I know what they go through,
because I also have experienced this: new job,
feeling lost, not knowing how things work, not
knowing how to speak the language. I think that my
challenge is not to get overly involved and not let
my personal side enter too much. (08)

At the same time, many psychotherapists referred to
the relationship with their patients as the most suppor-
tive element of the therapy and stressed how “being
and remaining there” gave patients a sense of stability
that was missing in their current situation: “Most
essential of everything is the bond. Without the bond
established, the psychotherapy does not occur” (14).
Trust was regarded as crucial and as strengthened by
transparency, by stressing confidentiality, and by con-
firming patients’ needs. Speaking the patients’
languages, showing an active interest in patients’ cul-
tures, and having passed through similar experiences
as patients were all seen as supportive for the
bonding process. However, the existence of similar
experiences was also discussed as a risk for overidenti-
fication. Similarly, while clear relationship boundaries
were supportive to some, others preferred a more flex-
ible understanding of the relationship, rejecting the
position of neutrality of the therapist.
Setting (S)
A variant hindering element was having to improvise
the physical space of the therapy since no established
structures existed (see Figure 2).
I dream, maybe I’m being whimsical and pretentious,
but having a cute little room permanently ready to
attend them with various chairs, maybe a table in
the centre. Because here it’s always that thing:
moving a chair to one side, moving a chair to
another. An improvisation many times. (06)
Typically, psychotherapists also described the lack of
interpreters as hindering, as it led to problems in
communication with patients.
Working outside one’s own practice was seen as
helpful by most. It was achieved especially by visiting
refugees at home, talking to them in corridors,
accompanying them to events, and by visiting other
relevant institutions. Secondly, therapists typically
stressed group therapy and co-therapy as supportive.
Group therapy enabled a symbolic family represen-
tation and allowed patients to create alliances and
gain diverse perspectives on their problems.
However, psychotherapists also reported that some
patients were at first reluctant to take part in group
therapy and preferred individual treatment. Co-
therapy, defined as the presence of more than one
therapist in a session with a single patient, was per-
ceived as supportive for therapists, because the pres-
ence of others in the setting and debriefing after
sessions counteracted therapists’ feelings of being
overwhelmed. It was also described as allowing for
multiple perspectives on cases: “The co-therapy
setting helps a lot as it enables a lot of perspectives
with people who had intercultural experiences
Psychotherapy Research 9
already. To see that what the person is talking
about can be understood in different ways when cul-
tures are different.” (06)
Lastly, while some participants stressed the impor-
tance of working with interpreters or cultural
mediators, others found it helpful to conduct
therapy in Portuguese, allowing patients to discover
a sense of language capability in a secure space.
Some described communication technologies as use-
fulness for dealing with language difficulties.
Approach (A)
With respect to their approach to the therapy, psy-
chotherapists firstly reported struggling with the
“trap of assistancialism”, i.e. the desire to help
patients immediately with everything:
That’s something we find challenging and we’re very
concerned about – being aware of our place and
trying to distance ourselves from the patient. When
the subject builds up these literal demands, such as
‘I need a coat or a plate of food’, we understand
that this is super important because these are survival
needs. But we try to understand that we are not the
ones who are going to offer it. Precisely so as not to
create a relationship of dependence between the
patient and us. (16)
Secondly, when taking culture into account as impor-
tant consideration in their approach, psychothera-
pists thematised cultural camouflage – that is, the
risk of overlooking patients’ psychological problems
– as a hindering element. Thirdly, few found it diffi-
cult to adapt their traditional therapy to refugee
patients’ needs.
At the same time, this adaptation was typically seen
as supportive and realizable through listening to
patients’ needs before intervening, and flexibly co-
constructing the process. Furthermore, stepping out
of the psychotherapeutic realm of their work was
highlighted as supportive: 13 therapists directly
addressed the need to assist patients in non-psy-
chotherapeutic ways, reconceptualising their work
as clinical-political:
Many psychologists here have this idea that: ‘in the
therapy we treat emotions, affections, feelings. Every-
thing that is outside – housing conditions, education
or social oppression – is not clinical. All that is for poli-
tics.’ We believe in the contrary: that a clinic has to be
attentive to political questions to be effective. The cure
does not only pass through feelings or emotions. It
passes through the social conditions which form the
structure for the person to build upon. (12)
Others referred more indirectly to the supportive
function of working outside the psychotherapeutic
10 G. S. Duden and L. Martins-Borges
Figure 2. Psychotherapy settings at three different centres in Brazil.
realm, such as by stating to engage in advocacy in
order to better patients’ context. In their approach,
participants furthermore stressed the importance of
focusing on patients’ strengths and supporting their
autonomy, for instance by connecting them with
public institutions. Providing a space for elaborating
on suffering, being truly present and listening to the
patient were generally regarded as supportive. As a
variant theme, non-verbal methods (e.g. art
therapy) were seen as facilitating bonding and sup-
porting patients’ self-efficacy. Addressing questions
of identity – for instance by stimulating conversations
about the patients’ countries of origin – was thought
of as helpful, as was working on the here and now.
Finally, the benefit of long-term therapy was thema-
tised as establishing continuity and enabling the for-
mation of a good working alliance.
Many of the themes are linked across levels. Three
of the most apparent links are represented in Figure
3: firstly, represented by the upper part of the
figure, therapists perceived that refugees’ enormous
contextual problems create uncomfortable feelings
in themselves, potentially leading to their overinvol-
vement (negative experiences depicted on the left
side in red). This makes structural competence and
collective work to “share” and “transfer” responsibil-
ity and for social support utterly important, as rep-
resented on the right side in green. Likewise,
adaptation to refugees’ needs, which sometimes
means going beyond the psychotherapeutic realm,
was seen as supportive to meet contextual challenges.
Secondly, and looking at the middle part of the figure,
culture and language differences can be hindering
elements, especially due to therapists’ ethnocentrism,
but can be overcome, for instance by working with
interpreters, receiving training in cultural psychology
and practising cultural decentring and humility.
Thirdly, the lowermost part of the figure shows that
establishing a trustful relationship, despite being
potentially difficult and lengthy, is a central suppor-
tive element of the therapy facilitated by a desire to
attend patients, speaking their language and being
truly present.
Discussion
The present study found that psychotherapists
working with refugees in Brazil experience supportive
and hindering elements in their work on eight levels
ranging from the individual to the broad societal
context. This supports the assumption that important
factors for the effectiveness of psychotherapy out-
comes are not limited to the psychotherapeutic
approach and method, but rather include character-
istics of therapists and patients, their relationship
and the context in which the therapy takes place
(Aveline, 2005; Drožek, 2007; Wampold & Imel,
2015). The three main aspects across levels will be
discussed here in regards to the scientific literature.
The Therapeutic Relationship
The therapeutic relationship was perceived by many
therapists as the most important part of the therapy
supporting the argument that collaboration and
therapeutic alliance, as elements of the therapeutic
relationship and common factors among therapy
approaches, consistently predict better outcomes of
psychotherapy (Aveline, 2005; Barber, 2009;
Wampold & Imel, 2015; Zilcha-Mano, 2019).
Hence, as highlighted before, the importance of
trust in the relationship became apparent, as did the
struggle to overcome patients’ initial mistrust,
arising inter alia from trauma, stigma of psychother-
apy and experiences of discrimination (Codrington
et al., 2011; Duden et al., 2020; Sandhu et al.,
2013). By emphasizing the importance of the
relationship and the difficulties in overcoming
patients’ mistrust, this study might provide a ration-
ale for long-term treatment approaches. However, it
is important to note that most of the participants in
this study had a background in psychoanalysis
which may have directed their focus to the thera-
peutic relationship and long-term treatment
(Doran, 2016). Studies have shown, that if therapists’
attention is drawn to the alliance, its effects on the
psychotherapy outcome increase (Zilcha-Mano,

Figure 3. Connections of themes across levels.
2019). Therefore, one might conclude that the
importance assigned to the therapeutic relationship
is circular: insofar as therapists perceive it to be essen-
tial, it becomes essential. However, the empirical
support for the importance of the therapeutic
relationship in general, and in work with refugee
patients in particular, is paramount and includes
studies focusing on diverse therapeutic schools such
as cognitive behavioural therapy (Mirdal et al.,
2012; Vincent et al., 2013).
Flexible and Collectivity-based Responses to
Contextual Challenges
In line with Drožek (2007), therapists stressed the
importance of considering the influence of social
determinants on mental health rather than focusing
purely on the inner-psychological problems of
patients, making therapists’ contextual awareness or
structural competence (Metzl & Hansen, 2014)
necessary. In the Brazilian context, predominant
challenges consist especially in discrimination of
refugees (Knobloch, 2015), in the unpreparedness
of the system to integrate refugees and the resulting
instability (Bógus & Rodrigues, 2011), and in the
lack of funding for mental healthcare in general and
for services specialized in refugees’ needs in particu-
lar (Doniec et al., 2018; Jubilut, 2006). The lack of
Psychotherapy Research 11
funding and services also becomes apparent from
the fact that none of the interviewed psychologists
worked with refugees as part of the public healthcare
system. Instead 14 participants treated refugees on a
voluntary basis without receiving payment, three
were supported by universities, and one by an inter-
national NGO.
Consistent with findings from other countries,
therapists reported feeling overwhelmed and helpless
in light of the contextual problems of their patients
(Apostolidou, 2015), but they also described how
such feelings could be overcome by reconceptualising
their work as clinical-political and by applying strat-
egies outside the traditional psychotherapeutic
realm, such as advocacy. It remains a debated issue
whether psychotherapists should intervene in
patients’ social or political context. In Brazil, this
debate relates to the differentiation between “tra-
ditional” clinical work (clínica tradicional) and
“extended” clinical work (clínica ampliada). The
latter type of clinical work is somewhat opposed to
“the cornerstones of the majority of Western therapies”
(Patel, 2003, p. 221) namely abstinence and neu-
trality, as well as the dominant view in traditional psy-
chology which revolves around individual and
isolated work (França Gomes & Dimenstein, 2016).
Defenders of neutrality in the therapeutic space pos-
tulate that psychotherapy works best when thera-
peutic expertise only, and not values of therapists
12 G. S. Duden and L. Martins-Borges
are employed (Fife & Whiting, 2007). However, it
has been argued that adopting a completely value-
neutral position in psychotherapy is impossible (Fife
& Whiting, 2007; Yamamoto 2012) and might risk
marginalizing patients even further (Jordan &
Seponski, 2018). Moreover, “traditional” clinical
work might imply a rigid, technical and biomedical
perspective. On the other hand, “extended” clinical
work, even though it might take into account the mul-
tidimensionality and complexity of mental health
problems, might dismiss valuable technical and
specialized knowledge (Marsillac et al., 2018; Yama-
moto, 2007). The present study supports the view
that, in the work with refugee patients, political and
psycho-social engagement constitutes a balancing
act for therapists: working with patients’ context
might lead to therapists’ overinvolvement and thus
counteract the goal of nurturing patients’ indepen-
dence and self-efficacy (Codrington et al., 2011;
Kronsteiner, 2017), hence jeopardizing the therapy
(Apostolidou, 2015). In addition, it might increase
the risk of psychotherapists becoming overwhelmed
by patients’ complex needs and so losing the capacity
to work effectively (Kronsteiner, 2017). On the other
hand, socio-political engagement of psychotherapists
can be viewed as an expansion of the therapist’s pro-
fessional role (Drožek, 2007), facilitating trust and
bonding (Karageorge et al., 2017; Watters, 2001),
and even as ultimately necessary when psychotherapy
is not prioritized by patients since basic needs are not
met (Apostolidou, 2015; Codrington et al., 2011).
Indeed, much of the literature on mental healthcare
of refugee patients shows that addressing refugees’
complex contextual and social needs through
psycho-social work, advocacy and practical assistance
seems especially helpful to patients and staff (Cars-
well et al., 2011; Codrington et al., 2011; Duden
et al., 2020; Karageorge et al., 2017; Watters, 2001).
A potential solution to this balancing act consists in
using multidisciplinary teams involving various pro-
fessions such as social workers and advocates as
well as collectivity-based strategies to support psy-
chotherapists from feeling overwhelmed by patients’
complex needs (Apostolidou, 2015). In line with
ample research, participants in the present study
highlighted the need for support structures for thera-
pists such as their own psychotherapy and supervi-
sion, as well as the helpfulness of collectivity-based
strategies in the therapy with refugees (Barrington
& Shakespeare-Finch, 2013; Duden et al., 2020) as
for example teamwork, co-therapy (Pocreau &
Martins-Borges, 2013), networks, and group
therapy (Drožek, 2007; Duden et al., 2020). This
focus on collectivity may not be surprising consider-
ing the fact that Brazil is the founding country of
community therapy and its healthcare system is
committed to social and community issues (Paim
et al., 2011). It is possible that, in the Brazilian
context, relationships with others serve as an indi-
cator of well-being, and collective concepts of
mental well-being and healing are more common
(Kirmayer, 2007). However, group settings have
also been favoured by others in work with refugees
(Drožek, 2007; Duden et al., 2020) as connecting
to people in similar situations might facilitate the
adaptation to a new environment and thus better
mental well-being. Collective settings involving
more than one therapist as well as therapists’ inser-
tion in interdisciplinary networks may also lessen
the burden on individual therapists and consequently
improve their ability to truly listen to patients and be
fully present in the therapy.
Language, Culture and Psychotherapists’
Training
The importance of language, translation and cultural
mediation, thematised by participants in the present
study, is widely recognized in research (Miller et al.,
2005; Mirdal et al., 2012). However, in this study,
only two of the 18 participants had sporadic access
to interpreters. Many compensated for the lack of
interpreters with their own language skills or by
attending patients who already had knowledge of
Portuguese, which naturally restricted the group of
people professionals were able to attend.
As ways of dealing with cultural differences, par-
ticipants in this study stressed theoretical and cultural
decentring and humility as central elements. Cultural
humility has been found to be a predictor for a good
therapeutic relationship and for positive therapy out-
comes (Hook et al., 2013), and it has been described
as a more flexible, adaptive alternative to knowledge-
based cultural competence concepts. Knowledge-
based concepts are a first step to highlight the impor-
tance of cultural factors in psychology, but risk to
essentialise cultures (Kirmayer, 2012; Tervalon &
Murray-Garcia, 1998). In line with this, the thera-
pists in the present study highlighted that, more
than studying patients’ cultures, they needed to con-
tinuously decentre their own values and theoretical
assumptions, which was facilitated by supervision,
genuine interest in patients’ country of origin
(Drožek, 2007), and training in cultural psychology.
Education in cultural psychology becomes increas-
ingly relevant for psychology curricula in universities
internationally (Griffiths, 2001; Knobloch, 2015;
Silva-Ferreira et al., 2019), as the world is experien-
cing a growing number of refugees and as claims
about the universality of psychological phenomena
receive more critical appraisal (Henrich et al.,

2010). Addressing the cultural traditions of thinking
about human nature, about mental health and
about therapeutic approaches in the education of psy-
chologists from an early stage onwards (Christopher
et al., 2014; Kirmayer, 2012) could enhance self-
reflexivity of psychotherapists regarding their own
theoretical and cultural standing (Kronsteiner,
2017; Tervalon & Murray-Garcia, 1998). Addition-
ally, therapists should be trained to express cultural
humility, for example by demonstrating openness to
patients’ cultural worldviews (Hook et al., 2013)
and recognizing patients’ beliefs and alternative
sources of help (Kirmayer, 2004; 2012). Moreover,
preparing therapists for the work with refugees
might require a focus on structural competence
(Metzl & Hansen, 2014), in other words, supporting
therapists’ general socio-political awareness (Jordan
& Seponski, 2018), sensitizing therapists to the
specific contextual and post-migration issues faced
by refugees (Griffiths, 2001; Watters, 2001), and
encouraging their reflection about how patients’ suf-
fering and the psychotherapeutic process are shaped
by the larger structural context in which they take
place (Metzl & Hansen, 2014). In doing so, edu-
cation programmes should avoid broad generaliz-
ations and stereotyping (Watters, 2001) as well as
rigid adherence to a theoretical orientation (Caston-
guay, 2011) and instead foster integrative
approaches, an attitude of flexibility in therapists
and an openness to explore and repond to the par-
ticular background, context and views of each
refugee patient (Savic et al., 2016).
Limitations
The present findings are limited by the fact that we
only obtained therapists’ perspectives. Future
research should take into consideration the experi-
ences of refugee patients in Brazil, as this might
provide insights into further supportive and hinder-
ing elements in the therapeutic process, including
potential discrimination by therapists. It might also
provide the possibility to evaluate whether patients
themselves find group settings as helpful as thera-
pists do. Another issue concerns the systematisation
of patients’ records. Since many of the participants
in the present study worked on a voluntary basis
and did not routinely keep records on their patients,
the present study could not provide data on how
many patients psychotherapists saw on average nor
on therapy duration. Future studies are needed to
provide more systematic and contextual information
in this regard. Such studies may be of great benefit
not only to the scientific community, but also to
support the Brazilian healthcare system, which has
Psychotherapy Research 13
been described as struggling from lack of intercon-
nectedness and systematisation (Böing et al., 2009;
Marsillac et al., 2018). Furthermore, the results of
this study included frequency counts, a debated
issue in qualitative research. Frequency does not
necessarily represent the importance of themes
since participants might have various reasons not
to refer to a theme (Braun & Clarke, 2019).
Finally, the primary researcher of this study is
German which, given the history of colonization,
may have limited the extent to which participants
in Brazil felt comfortable to articulate their point
of view (Watters, 2001). However, the research
team also included Brazilian researchers, and care
was taken to establish rapport with participants
through prior informal conversations and transpar-
ency, and the interview questions were formulated
very openly.
Conclusion
In conclusion, psychotherapy with refugees seems to
be an emergent issue in Brazil. It faces many struc-
tural challenges, as does Brazilian healthcare in
general, especially in light of recent political develop-
ments that indicate a move away from the unified
healthcare system (Doniec et al., 2018). Psychother-
apeutic work in this field certainly needs to receive
higher appreciation considering, for instance, the
fact that most of the psychotherapists in the present
study worked on a voluntary basis with refugee
patients. On a wider level, more policies and better
implementation strategies for the integration of refu-
gees are urgently needed, as is the creation of inter-
disciplinary networks to attend the diverse needs of
refugees appropriately. With respect to the education
of psychologists and psychotherapists, universities
should shift from a unidimensional psychotherapeu-
tic education (Castonguay, 2011) to fostering inte-
grative approaches, theoretical decentring and the
structural competence, flexibility, open-mindedness
and cultural humility of therapists. Internationally,
taking the perspectives of Brazilian psychotherapists
into consideration might help to develop a more col-
lectivity-focused and contextual understanding of
mental health and therapeutic processes and thus
advance investigation and application of community-
and network-based approaches for bettering the
mental health of refugee patients.
Acknowledgements
We would like to thank the participants who took part
in this study and the anonymous reviewers for their
constructive comments on our article. Gesa Duden
14 G. S. Duden and L. Martins-Borges
gratefully acknowledges a research fellowship from
the Hans Böckler Foundation. We wish to express
appreciation to all the people who helped support
this study by pilot testing the interview guideline,
assisting the transcriptions and coding of the inter-
views and by proofreading the manuscript, in particu-
lar Alisson Vinicíus Silva Ferreira, Darragh O’Shea,
Felicity Parker, Kosta Gligorijevic, Luiza Marson
Morais, Maria Heydel, Paula Campos Andrade,
Raphael Didjurgeit, Samanta Borges Pereira,
Thiago Guedes Willecke and Vagner Perez.
ORCID
GESA SOLVEIG DUDEN http://orcid.org/0000-
0002-3196-0755
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