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Choosing a Different Path: Muhabet and an Alternative Approach to Recovery

“When you, as a foreigner in Denmark, are hospitalized in a psychiatric department you experience double isolation. You are isolated because of your mental illness and because of your
foreign background, which makes it difficult to understand the language and the things around you. Being mentally ill simply hits you harder as a foreigner than if your last name was Hansen
or Jensen.” –Najib Haddar, Founder of Muhabet
In Denmark today, approximately 25-30 percent of all refugees are traumatized from their experiences of war and torture, and their flight from it. Even after finding refuge in Denmark, this group’s battle for survival is still not over, as they continue to fight the various mental illnesses that have developed as a result of their past. Unfortunately, the Danish treatment system is currently failing these traumatized refugees. All too often, these people cannot gain access to the treatment they need either because there is simply not enough room for them at the treatment centers, or because the treatment they get is not adequately suited to their specific needs. Most importantly, the Danish system often fails to embrace basic human and social needs as part of the rehabilitation process, such as building a strong support system and re-establishing normalcy in their lives, a necessary step to a successful recovery.
All of these factors help to maintain that double isolation that Najib Haddar spoke of.  As a result, several experts strongly suggest that many traumatized refugees are in fact getting worse and becoming even more traumatized after their arrival in Denmark. As Bente Rich, a well-known psychiatrist who treats refugees, states:
“If they were in a society where they were recognized as human beings who have something to offer to society, then it would not be that bad. But the isolation and the constant feeling that they meet every day, that they are marginalized and not wanted, 
will cause them at last to develop PTSD [Post Traumatic Stress Disorder]. I think even the strongest person is not able to cope with that.”
But in the midst of all of this hopelessness, there are a few people who are trying to correct the system and change the outcome of these refugees’ lives. Haddar and his wife, Emine Ayyidizoglu, started Muhabet in 2003 in order to give traumatized and mentally ill refugees and immigrants a place to go, where they can be themselves and be seen, heard, and respected for that. Although Muhabet is not a treatment center, it has treated many souls that come through its open door. Muhabet caters to the very basic and instinctual needs of its guests by creating a network of support and embracing its visitors and their original cultures, something that the Danish treatment system is far from accomplishing. It brings back the dignity and normalcy in their lives in an open, safe, and comfortable environment when most of Denmark is turning its back on them, not only because they are mentally ill but also because they are foreigners. 

PROBLEM IN THE DANISH TREATMENT AND REHABILITATION SYSTEM

But why is it that the Danish system of treatment and rehabilitation is failing so many of its patients? What are the challenges that the system faces when treating traumatized refugees from different backgrounds? And how is it that so many people are not being helped? 
Capacity and Organizational Insufficiency
One of the largest and most immediate problems within the Danish treatment system is the severe limitations in capacity, as there is a one to two year waiting period for most traumatized refugees before they can actually begin treatment. The capacity problem is, however, simply a reflection of larger organizational issues of the entire system, whereby the geographical distribution of centers and separation of treatment disciplines often causes patients to fall through large cracks in the system. For example, Dr. Rich explained a story in which one woman was not able to get treatment because the rehabilitation center was located too far from her home. Because she had to attend the required language classes in order to receive social benefits and also had to take her children to school, it was physically impossible for her to travel to the center to receive treatment. As Dr. Rich notes, “We made a system where it looks like we take care of them, but we have constructed it so that we don’t actually help them.” Another issue arises from the way in which the system is divided, as the rehabilitation centers are separated from the general health care system. As a result, patients who may present more than one psychiatric symptom in addition to PTSD are bounced back and forth in an extended ping-pong match between the normal psychiatric center and treatment center. 
Lack of Knowledge of Treatment for People with Different Cultural Backgrounds
Aside from the structural flaws found in the Danish treatment system, serious issues arise from the deficiency of professional training and knowledge relating to treatment of traumatized refugees from different parts of the world. Najib explains, “There are a lot of misunderstandings within this field because of the cultural and language divide that exists between the patient and the psychiatrist.” The use of interpreters varies from hospital and center, but some interpreters are not trained to deal with trauma victims while others are simply not trained in interpretation at all. 
Combating the language barrier between doctors, psychiatrists, nurses, social workers and their patients is extremely difficult. However, the true challenge to defining illness and understanding different treatment possibilities comes when not only language, but culture, exists as an obstacle. 
 
Marianne Østerskov, a nurse at the Center for Trans-Cultural Psychiatry at Rigshospitalet, works to educate the psychiatric field on the challenges and issues of treating patients from different cultural backgrounds. The Center’s goal is to teach the professional community that culture must be taken into account when treating patients of other backgrounds, as it not only affects the way in which these patients may interact during their treatment, but also the way that they perceive their illness altogether. As she explains, “I teach people that it is important to see a patient’s background, to listen to him, and to see what he thinks of his illness, how he understands it, and how he will explain it because there can be many different explanations of illness.” She goes on to stress that mental illness represents a serious taboo in some of the countries that refugees have fled from, and therefore, it is even more important to communicate about the way that mental illness and treatment are viewed in Denmark, and how that may differ from the prevailing view in the refugee’s home country. 
Just as professionals, doctors and nurses may not be aware of the different possible understandings of what it means to be mentally ill and to receive treatment, Marianne notes that they may not always understand what it actually means to be a refugee or immigrant in a foreign country. For both professionals and patients, it can be very hard to navigate such an unfamiliar culture and life. However, it is important for the professional to understand the drastic difference between a traumatized Dane and a traumatized refugee in order to create an effective treatment plan and establish a trusting relationship. As Marianne clarifies, “I am not sure that we as professionals are always aware of what this deep loss means to the patient and of all the grief that they carry heavily inside themselves because of it.” Given that it is this grief which displays their humanity after having been so deeply dehumanized by what they have been through, to not understand, appreciate, or recognize it would only be to dehumanize them even more. 

The Dehumanization of the Patient

The most significant problem of the Danish treatment system is its dehumanizing effect on of the patient, as the illness remains the primary focus throughout the treatment process.  Focusing on the illness does not require that the patient be treated as if he is just the illness, a thing that needs to be treated. Often, however, he is simply viewed as a client, forcing his “humanness” to take a backseat to his illness and leading the traumatized refugee to become further dehumanized in his path to recovery.  As Dr. Rich explains it, “We have taken away the idea that they are respectful and equal subjects, playing a part in their own life and their own recovery.”  Because there is such a strong preoccupation with the illness itself, the patient’s voice, personality, and input is often not heard or encouraged. 
This objectification of the patient can often be seen in the simple interactions with his doctor, as they plunge straight into the medical questions without checking up on how he is doing emotionally or socially. Reflecting on some of his experiences in hospitals, Najib explains,
“Take for example a refugee from Iran, Pakistan or Afghanistan who arrives in Denmark. They are reduced to an object instead of a human being. When they go to the hospital the psychiatrist asks you questions like ‘are you shaking, how is your stomach doing, do you go to the toilet three times a week, do you sleep a lot’, and totally leaves out more personal questions like ‘do you miss your mother, the bazaar, the heat, smell of camels’ or something like this. The human and cultural dimension of the patient is completely ignored.”
Marginalizing a patient’s human identity during the process that is designed to help them recover it is not only counterproductive to the treatment effort but more importantly, degrading and demoralizing for the patient. In treating traumatized refugees as objects or as the mere sum of the illnesses that plague them, doctors, psychiatrists, nurses, social workers, and anyone else adopting this attitude are in fact removing the last bit of hope for a full and successful recovery. However, there is another approach to interacting with the patient.  As Dr. Rich suggests, “By doing the opposite, by recognizing and reaching out to the humanity within them, you are taking the first step to meet them and are reaffirming for them that they are not just objects in a society that wants them to leave and not be here. This sort of humanity in action is the very first step.” 
Muhabet takes that first step in a very profound way.

MUHABET: A DIFFERENT KIND OF “TREATMENT”

Muhabet Means Togetherness

To give mentally ill refugees and immigrants in Denmark a little piece of humanity is exactly why Najib and Emine opened the drop-in café Muhabet. They wanted to give this vulnerable group - often forgotten by society - a place to come, relax, find peace and meet other people. But it is also a place to make the outside world aware of their existence. “We are part of the community. Why should we hide ourselves at the psychiatric unit or in our homes?” says Najib. 
The inspiration for setting up this café stems from Najib and Emine’s many years of experience with the Danish system of treatment and rehabilitation for mentally ill refugees and immigrants. They find the system to be inhumane and incapable of reaching the people who most need it, who are marginalized and socially isolated due to their mental illness and language barrier. Najib explains this when discussing his former job as an interpreter: 
“For many years I was the fly on the wall. I saw the miscommunication between psychiatrists, nurses and patients and I thought that this we must be able to do in a better and different way.”
Therefore, the couple decided to open Muhabet in order to create a space of physical and mental freedom for one of the most excluded and isolated groups in society, meeting them with a unique combination of warmth, understanding and respect. Muhabet offers its guests a break from the day, which for many is marked by isolation, loneliness, and struggle;  because of this, its guests have learned to cope and live with their illness more effectively. As one guest describes, “I used to have stomach pain before I came here and it lasted all weekend. After I started coming here and talking about the old days and eating a meal, the pain has disappeared from my soul.”
In Arabic countries, Muhabet means “togetherness,” and this word very well describes the core values of the small café in Copenhagen. The place is designed like a regular café, with sofas for people to relax and visit on. Flowers, decorations, drawings, and the warmly colored walls remind the guests of home and create a cozy atmosphere. The café has four fulltime employees and a broad network of volunteers, who jointly offer Muhabet’s guests companionship, compassion, understanding, and a free meal.
Muhabet is driven by its philosophy that people with a mental illness also have an intact healthy side of themselves, a side that can be stimulated through an appeal to the senses, humor, and social interaction. Through these experiences, the person can  recover – at least, in certain respects - by breaking their social isolation through interaction with others. Thus, Muhabet offers its guests a place where they can experience being part of a social atmosphere with other people, where they are seen and recognized for being exactly the people they are, in order to establish a sense of dignity. As Najib explains it: “It’s all about seeing others and being seen yourself.” Through emotional attention and recognition, Muhabet facilitates the development of self-confidence and self-esteem in the individual. As one guest shares, “I was very low when I started coming to Muhabet, but now I am a mother to my children.” 

The Muhabet Approach

So, what exactly happens inside this small café that makes Muhabet such a positive influence in these traumatized refugees’ lives? How can it be so effective at indirectly treating people when it is not a treatment center, while the official public treatment and rehabilitation system seems to fail its patients so often? 
One difference is that in Muhabet, the conventional term “client” is replaced by the notion of a “guest.” Here, the people working and volunteering at Muhabet are seen as the hosts, while the visitors are their guests. When an individual is referred to as a client, an uneven power dynamic is created between him and the person he is interacting with, immediately placing him in a subordinate position. By referring to people as their guests, Muhabet’s staff and volunteers eliminate this power dynamic, helping to remove the barriers and distance between the immigrants or refugees and the volunteers working at the café to create an atmosphere of trust and equality. As Najib explains, “We do not have badges or name tags. So when you come here you actually don’t know who is a member of the staff and who is mentally ill. And that is exactly the point. We are not different from each other. We are just human beings.” Muhabet also does not register any of its guests, attempting to promote an environment of trust in which people are greeted just as themselves. There is no hidden agenda, no expectations or requirements for their guests; it is simply a place for them to be who they truly are. 
Another important aspect to Muhabet’s approach is that they work very deliberately and consciously with the senses, stimulating them through food, music, and smells. As Najib explains it, “No matter how bad you are feeling mentally, one's senses still work, and they are the ticket back to a time when things were different.” Along these lines, Muhabet provides music, food and decorations that remind its guests of their home countries, in order to wake something inside of them that is neither sick nor sad. "The smell of food, music, the taste of tea and so on is not only capable of raising good memories, but it also penetrates through the disease and touches upon what is life," explains Najib. A free hot meal is served every day at two o’clock, which, according to Muhabet’s staff, is extremely important for their guests because when you are mentally ill and alone, you simply do not have the energy or sometimes the option to buy and cook tasty, healthy food. As one Muhabet guests says, “When the stomach is full, your head sings.” Lastly, Muhabet plays recognizable music from all over the world, catering to the different homelands of all its guests. The people can dance and sing if they want, or can just sit on the sofa and enjoy the music. "We want a place where the sound creates memories of another time in the guests. That's why we play music from all the countries that our guests’ come from," explains Najib. 
Ultimately, one cannot deny that Muhabet’s guests in some way receive both emotional and social treatment when they visit the café, even though Najib and Emine are adamant that Muhabet is not a treatment center and should not be perceived as such. This approach goes very much in hand with their policy of meeting guests with respect and dignity, and seeing them as more than just the illness that affects them. As Najib declares, “By not offering treatment, we recognize the person as he is, and we do not try to change him.” In fact, a guest’s illness, medication, and treatment are never brought up at Muhabet unless he himself initiates the conversation. The illness is not the focus at Muhabet. The person is. 
A contact staff at the district mental health department thanked Muhabet for its effect on her patient Wahid, saying, “Thank you for a fantastic couple of hours at Muhabet. Especially thank you for making Wahid laugh and tell jokes, he hasn’t done that in a long time. And thanks for telling me that he keeps coming as planned. It is a huge victory for him!” 
By focusing on Wahid as a person and connecting to him through humor, Muhabet was able to positively affect him, even though the illness and its symptoms were never once discussed. As Najib says, “We do not talk a lot about diseases. But we follow their lives. We live with their disease, sorrows, and joys.” That relationship, which is made up of respect and mutual understanding, can often be the first step toward recovery.     

MUHABET AS A SOURCE OF INSPIRATION

For the last six years Muhabet has served as an oasis, a safe haven, for traumatized refugees, immigrants and their families. While it has been emphasized time and time again that this is not a place to go to receive medical treatment, Muhabet nevertheless provides medicine for the soul to all of its guests; something that the conventional Danish system has not been willing or able to provide. Because of the powerful influence it has had on so many individuals’ lives, Muhabet can and should serve as a source of inspiration to the Danish treatment system. 
Muhabet’s multicultural approach can serve as a powerful tool in overcoming the cultural divide that often arises between a traumatized refugee and his psychiatrist, nurse, or social worker. Professionals who are able to better understand their patients’ culture will be able to more effectively treat their patients, by avoiding misunderstandings and miscommunications. “You have to make the effort to get to know the person in order to treat the patient in the best way. And if you don’t do that, the treatment will be half and superficial,” says Marianne. 
Muhabet has also shown us that the embracing of one’s culture can act as a form of treatment on its own. By reminding the senses of something familiar and pleasant, whether  through food, music, or atmosphere, positive memories of life before illness can have an empowering effect on the individual and his recovery. As Dr. Rich explains, “It is a very good idea to remind them about their culture because they have some diamonds in their luggage, and we have to remind them about it. We have to support them so that they do not to forget the good parts they had in life.”  
In addition to its multicultural approach, Muhabet’s practice of always viewing its guests as the individuals that they are, rather than the illnesses that they have, should serve as the model for interacting with and treating traumatized refugees and immigrants in all aspects of treatment. Dr. Rich suggests that when the psychiatrist or nurse is genuinely interested in their patients’ lives and wants to meet them as the people they really are, as they do at Muhabet, this is the best way to initiate the recovery process. 
While Muhabet’s multicultural and humanistic approach are important factors in its success, the strong social support network it provides for its guests may represent the most critical element lacking in the Danish treatment and rehabilitation system. One of Muhabet’s most powerful effects is to remove guests from the isolation created by their illness and by their status as foreigners in Danish society. The traditional treatment system, in contrast, does not prioritize or create the support network needed to restore stability and normalcy to their everyday life. Breaking this isolation is the foundation upon which all recovery and treatment must be built. 
Muhabet stands alone as the only drop-in café specifically established for traumatized refugees and immigrants. While more private initiatives like Muhabet would be beneficial, the real challenge lies in changing the Danish system. These treatment and rehabilitation  facilities and programs need to adopt aspects of Muhabet’s multicultural approach and underlying values, if they are to reach those who are currently being failed by the system.  

References

Personal Interviews

• Brandt, Preben. Psychiatrist and founder of ”Project Outside”, June 30th, 2009.
• Folke, Nana. Student helper, Center for Udsatte Flygtninge, Dansk Flygtningehjælp.
• Haddar, Najib & Lise Poulsen. Founder and administrator of the drop-in centre Muhabet in Copenhagen, June 30th, 2009.
• Rich, Bente. Child and adolescent psychiatrist, June 30th, 2009. 
• Østerskov, Marianne. Project Nurse at the Center for Trans-Cultural Psykiatry at ”Rigshospitalet” in Copenhagen. June 30th, 2009.

Articles

• Auken, Gunvor “Brug værestedet Muhabet som inspirationskilde”, Information, 17th of November, 2008.     
Wepage: http://www.information.dk/172109
• Elmer, David and Morten Bjørn Hansen, 3.000 indvandrere kom på førtidspension sidste år, Infomedia, May, 2009.
http://woview.infomedia.dk/?url=http%3A//agenda.da.dk/supershowdoc.asp%25K3Fpid=20090527144952LJS&OpointData=20ed0f5176f165fcad57a0b180a24223JmlkX3NpdGU9MzA0MSZpZF9hcnRpY2xlPTE3NTAmaWRfdXNlcj01MTk4JmlkX2FwcGxpY2F0aW9uPTEwMDAyODgmaWRfcGFydG5lcj00Jmxhbmc9ZGEmbW9uPTEmbWF0Y2hlcz0iZGFuc2sgZmx5Z3RuaW5nZWhqw6ZscCI0ICJmbHlndG5pbmdlaGphZWxwIjYgImZseWd0bmluZ2VoasOmbHAiNyAiaW50ZWdyYXRpb24iOCAiZmx5Z3RuaW5nZSI5ICJpbmR2YW5kcmVyZSIxMSAiaW5kdmFuZHJlcm5lIjEyICJpbmR2YW5kcmVyIjEz
• Arbejdets betydning for flygtninge med traumer, Center for Udsatte Flygtninge, 2009.
http://www.flygtning.dk/fileadmin/uploads/pdf/Integration/CUF/Materialer/Forskningsoversigt_med_forside_01.pdf 
• Rehabilitering og behandling af flygtninge med traumer, Center for udsatte flygtninge, February, 2008
http://74.125.77.132/search?q=cache:z1CqqxEUpYkJ:www.flygtning.dk/fileadmin/uploads/pdf/Integration/CUF/Materialer/Microsoft_Word_-_Notat_om_rehabilitering_og_behandling__februar_200.pdf+flygtninge,+traume,+behandling&cd=4&hl=en&ct=clnk&client=firefox-a 
• Muhabet - kærligt og åndeligt samvær, Bodil Kristensen, Center for frivilligt socialt arbejde, Frivillig. Nr. 76, 2005.
http://www.frivillighed.dk/Webnodes/da/Web/Public/Publikationer/Frivilligfronten/Muha bet+-+k%E6rligt+og+%E5ndeligt+samv%E6r
• Kunsten at åbne et vindue - nye tiltag i arbejdet med psykisk syge fra etniske minoritetsgrupper, Clea Jerlang, Center for trans-cultural psychiatry, 2008.
www.vftp.dk/produkter/.../kunsten_at_aabne_et_vindue.rtf
• Satser på sanserne, Marianne Bjergborg, Center for social psykiatry, April, 2007.
http://www.socialpsykiatri.dk/vidensbase/bladet/2007/blad-nr.-4/satser-pa-sanserne
• Værested for psykisk syge, Det nationale forskningscenter for velfærd, October, 2006.
http://www.muhabet.dk/sider/presse.htm
• Muhabet – Værested for psykisk syge med indvandrerbaggrund, Mette Nielsen and Signe Gottlieb, PsykiatriFonden.
http://www.muhabet.dk/sider/presse.htm

Reports

• Muhabet - en oase i storbyen, Socialt og Pædagogisk Udviklings- og Kursuscenter, april 2008.
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Denmark Denmark 2009

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