12. Advanced Clinical Reasoning

The life situation of people with refugee experience is complex and characterized by various factors that influence their lives. Knowledge and understanding of these factors are difficult for healthcare workers to develop, because in most cases the circumstances are completely unknown and therefore more difficult to understand. Good interviewing, careful listening, and special empathy skills are necessary to develop a sustainable client-therapist relationship in this context. Special attention must be paid to the context, which in most cases will be very new and perhaps unfamiliar for clients with refugee experiences.

This approach is, for example, underpinned by the research project ‘Using the International Classification of Functioning, Disability and Health (ICF) to describe the functioning of traumatized refugees’:

The aim of this project was to use the International Classification of Functioning, Disability and Health (ICF) to develop an interdisciplinary instrument consisting of a Core Set, a number of codes selected from ICF, to describe the overall health condition of traumatized refugees. We intended to test 1) whether this tool could prove suitable for an overall description of the functional abilities of traumatized refugees before, during and after the intervention, and 2) whether the Core Set could be used to trace a significant change in the functional abilities of the traumatized refugees by comparing measurements before and after the intervention (Jørgensen et al. 2010: 57).

We successfully developed a Comprehensive Core Set with 106 codes describing common and important aspects of traumatized refugees’ health conditions. The result might have been a little different if the procedure had been carried out by international experts selected by certain criteria, but probably not in any decisive way (Jørgensen et al. 2010: 57).

Have a look at the interaction between the components of ICF:

In addition to the effective utilization of the ICF, incorporating other assessments can be advantageous. Good interprofessional cooperation enables the coordinated use of profession-specific assessments. Given their unique focus on the respective subject areas of different health professions, these assessments can yield valuable insights that benefit the interprofessionally coordinated therapeutic process. Moreover, interprofessional coordination of assessments helps to prevent duplication of assessment procedures and avoids inefficiencies and unnecessary burdens for the client. It also fosters mutual knowledge within the interprofessional team, facilitating the development of an effective team reasoning process for therapeutic decision-making.

In order to broaden understanding of the life situation of people with refugee experience and to enable more in-depth professional reasoning, two personal experience reports are detailed in the following sections of this chapter. The original voices of people with a refugee background are important sources of information in understanding their life situations. These personal experience reports will provide the reader with the opportunity to mentally scrutinize and apply the framework and content discussed in the preceding sections of this chapter.

The following text was written by Amira* (*name changed), a 45-year-old freelance journalist and children’s book author from Damascus, Syria, and a single mother of three children. In 2015, she fled Syria via the Balkans with her youngest daughter and her elder son and came to Germany. It was only four years later that Amira managed to bring her middle son—shortly before his 18th birthday—to Germany via a family reunification procedure. For the first few years, Amira lived with her children in various refugee shelters in southern Germany. Since 2019, Amira has been living in her own flat with her daughter and middle son. Today, her sons live in shared flats in the same city.

I love writing! As a child I used to write and read the texts to my mother. If my mother thought it was good, it was good enough for me. If she didn’t like something about my writing, then I wasn’t happy either. I always tried to write. I often sat in my room for hours and created stories.

When the children started school, I finally got the chance to work for an agency that produced children’s books. They published books for children from 1 to 12 years old. My job was to check the texts first. During this time, a colleague of mine found out that I write texts myself and asked me if I could show her some of my texts. She read my texts and was enthusiastic. I told her that I only write for myself, without a bigger plan. She asked me if we could show the texts to our boss. And so, I started writing for the publishing house.

I worked a lot during that time—copywriting, graphic design and I wrote my own stories on the side. But then the unrest in the country began and finally the war broke out. That’s when I started working as a clandestine journalist. I travelled to places that were affected by the war and reported on the situation on the ground. I talked to many people and documented the crimes. It was very stressful work, but I wanted to help and give people a voice through my reports. The texts were then taken abroad. It was very dangerous work. After two years it became too dangerous and I was afraid for my children. My mother finally told me to leave the country.

Then the publishing house I worked for also left the country. In my office there was a drawer with all my written work. There were many notebooks that I had filled by hand. I only wanted these texts. It was my story—the story of my life so far. But I was told they were all destroyed. I didn’t care so much about the children’s books, but much more about my private texts. I didn’t have a copy; it was all handwritten. But I didn’t get anything back.

Then came the escape.

I fled with my youngest daughter and my older son. Actually, we wanted to go to the Netherlands, but with a group of refugees we finally ended up in Germany.

At first, I thought I could manage everything, learn the language quickly, and catch up with my son within a few weeks. I thought I only needed one year and then I could work as a writer again—or so I had heard. You only need one year to learn the language and then you move on. But I experienced one trauma after another in Germany. The first camp was very bad. We shared a room with many other people, the food was very bad, we had little money, and no idea what to do.

I had no orientation and didn’t know what to do to change this state of waiting. It was very hard for me—always waiting. I was in the country for seven months without access to a language course. I tried to learn the language through YouTube videos. I learned a few simple phrases, like “My name is ...; I have children...”. I kept asking for a language course, but I was told that I couldn’t take part in any language courses without papers. When we moved to the next accommodation, my daughter got a place at school. Every day I had to take her to school and pick her up. It was only in the third accommodation after a year in Germany that I was able to start my first language course.

Before that, I could only communicate in English, and in the camps, there were sometimes projects run by volunteers. When I heard about them, I went and learned a bit. That’s why I was able to join the first official language course at A2 level. At first, I was very good, but then I don’t know exactly what happened. Maybe it was because I was very unhappy at the camp or because of my stressful situation? I had imagined everything so differently. Everything was incredibly difficult—learning the language, finding work, worrying about my children and the many foreign people around me.

And when I sought medical help, I had to understand everything that was said, but I didn’t. That made me very angry and sad. But I swallowed my anger—all day long. All the difficulties in everyday life: with the social welfare office, the job centre, the situation of my children, and I still had no residence status and no papers.

I didn’t ask for help and instead tried to sort everything out in English, but my head was often too full. Too full to understand everything and I just felt sad. And I really tried to learn, but I don’t know why what I learned didn’t stay in my head. I’ve had the problem for a long time that I forget a lot. But I thought I could do it: I can learn German, I can work, I can start a new life. But I have lost that feeling.

I wanted to try everything to make it better and I started a trauma therapy. There they tried to explain my situation to me. There is no certainty, but maybe I have a trauma and because of this trauma this blockage in the brain happens. My head wants to protect me and that’s why I can’t remember. I don’t know.

One year after therapy I still have the feeling I am very deep down and I need a lot of time to come up again. And for that I need a lot of energy, a lot of strength and time. I hate it when I need help. I hate the feeling and, so far, I need a lot of help—with translations of letters from the authorities, with financial questions, just for everything, and I hate this feeling. And I hate it when I have to ask my children for help. And it makes me sad and angry when my children say to me that I need to do more. I feel bad and stupid when I have to ask for help. My head is empty.

But what should I do? What can I do? It’s like my teacher said: language is the key here in Germany. If you don’t know the language, you don’t have the key. For example, when I get a letter and I don’t understand anything. I have to translate everything and still I don’t understand it properly. I have done very stupid things because I didn’t understand. I never said I didn’t understand and I usually try to manage on my own. My problem is, I have read and translated a word a thousand times and then I have forgotten it again. Why does this happen? It makes me very sad—where is my voice, where has my language gone?—I miss writing.

The following summarized text describes the current life situation of Ousman D. He comes from the Gambia and is now 23 years old. The interview with Ousman took place in October 2023. A lengthy escape, an initial stay in Italy and his arrival in Germany as an unaccompanied minor refugee preceded the interview. Ousman arrived in Germany in 2017. He completed his schooling here up to year 10. Ousman now speaks very good German and trained as an occupational therapist from 2019–2023. He has been working as an occupational therapist in Germany since 2023.

The unique situation of individuals who have fled with a serious illness or significant health restrictions, often in pursuit of better health outcomes abroad, should be particularly emphasized. The challenges of this huge transition—which involves not only leaving one’s continent and home country, but also acclimatizing to a new ethnic group, social system, and language—demand tremendous adaptive efforts. Ousman’s aspiration to become an occupational therapist emerged from this transformation, which he accomplished with enormous commitment and perseverance. His learning situation in a class of prospective occupational therapists was characterized by his profound thirst for knowledge, open-mindedness, self-confidence, and commitment. Inclusion in a cooperative learning group, alongside a reliable educational supervisor and empathetic teachers supported Ousman in his ambition to become an occupational therapist.

Ousman offers the following insights into his everyday life, daily routine, and leisure activities.

Insights into everyday life:

I am currently still on holiday and have not yet commenced my new job, which I will begin next month. I mainly spend my days at home, where I engage in sport to clear my mind. Additionally, I work at my part-time job three times a week. I also like to watch TV to relax and recharge before starting work.

Daily routine:

When reflecting on my daily routine, I must admit that I do not currently enjoy waking up early. I often spend my evenings watching TV until late at night, which results in me falling asleep around half past two and waking up around eleven in the morning. This habit is not just a result of being on holiday, but has also manifested itself during other phases of my life. However, once I start working, I will need to adjust my rhythm.

Leisure activities:

In my free time, I am passionate about sport. I regularly go to the gym and play football, occasionally serving as a coach for youth teams. One of my favourite things to do at home is cooking; I enjoy trying new dishes as well as connecting with my culture through traditional food.

Ousman also provides insight into how he manages his illness and assesses the services provided by the medical system. His narrative illustrates the reality of his life, his coping mechanisms for illness, and the burden of stress.

Health:

When asked about my health, I disclose that I have lived with a serious illness all my life. However, thanks to the medical care in Germany, I have the disease well under control. Despite occasional impairments due to changes in climate and the associated discomfort, I never give up. With perseverance and a willingness to face challenges, I manage to lead a largely normal life. Although hospitalization is sometimes necessary, I strive to live in harmony with my illness and build a kind of relationship with it that enables me to remain healthy and strong despite everything.

Medical care:

I have been living with a particular illness since childhood, and it will probably accompany me for the rest of my life. Nevertheless, thanks to the medical care available here in Germany, it is possible to alleviate the symptoms and manage the disease better than would ever have been possible in my home country. Taking medication regularly and having regular check-ups with doctors approximately every six weeks are essential for keeping the illness under control. Checking my blood and liver values is particularly important, as it allows me to ensure that everything is going well. Compared to my home country, where medical appointments were infrequent and usually not attended for financial reasons, this represents a significant improvement.

During my time in the hospital, I frequently noticed that communication problems exist not only between patients and medical staff but also within the medical team itself. It is therefore essential that everyone involved, from doctors to therapists, communicates regularly and works together to ensure holistic care. My experience shows that when such team agreements take place, patient care can be significantly improved.

Finally, research is another critical area that needs to be improved in order to sustainably strengthen and expand the healthcare system. Self-help groups in particular offer a valuable resource for individuals facing similar challenges. They provide not only knowledge and support, but also a sense of community and understanding that is difficult to find outside of the clinical setting.

To summarize, I would say that effective communication, cross-cultural understanding, teamwork, and ongoing research are the pillars on which a robust and inclusive healthcare system should rest. It is my hope that by promoting these aspects, everyone, regardless of their background or experience, will be able to access quality healthcare and feel at home within the German healthcare system.

While I have no immediate family in Germany, I am surrounded by friends from my home country who also feel well cared for here. Most of them have not experienced any major problems with the healthcare system, apart from one friend who tragically died because his illness was recognized too late—a fate he might also have suffered in our home country. These experiences illustrate that, overall, the German healthcare system provides reliable support for individuals like me who have come to this country for various reasons.

Although my friend’s issue was recognized, it was unfortunately too late to do much about it. A few months later, my friend passed away, which is a tragic reminder of the importance of timely medical intervention. That said, I have observed that many of my acquaintances have fewer health problems, apart from the stress caused by the system itself. In fact, I myself sometimes feel the pressures and stresses of the system. Nevertheless, I strive to come to terms with it and live with it; adaptation is a part of life here in Germany.

Ousman D.’s educational path highlights aspects of his personality characterized by strength, determination, and self-confidence despite facing significant resistance, misunderstandings, and illness. From the perspective of clinical reasoning, it is evident that these personal values can be revealed through trusting interactions (interactive reasoning) (Crabtree 2010: 119). Discussing the client’s personality within the interprofessional team and with the client themselves enhances the likelihood of providing individualized and maximally supportive therapy and consultation.

Professional career:

Regarding my professional career, I am about to embark on my new role as an occupational therapist. After arriving in Germany, I faced numerous challenges to discover and pursue this career path. Training to become an occupational therapist was demanding, but also very fulfilling. I successfully graduated and received numerous job offers. I have chosen a position that is close to my heart and am excited to start in November.

Key moment:

The healthcare system in Germany has opened up new perspectives for me, not only in terms of my own healthcare, but also in terms of my professional development. It has demonstrated to me the value of access to quality healthcare and the importance of contributing as part of this system.

to be able to address the multiple needs of refugees’ health through multiple coordinate professional competencies […] [c]ollaboration enables health professionals to achieve better health outcomes as it allows them to exercise their expertise in their specific area of practice while communicating their different perspectives with other professionals working with the same service user (Zwarenstein et al. 2009).

This creates a more adaptive and stable starting point for clients in the healthcare system on their path to better health.