When a young Kurdish man hosted in a temporary reception center in Milan started swiping through some pictures on his phone, one of the center's staff members was shocked by what he saw. An image of a man hanging by his neck appeared on the screen. "This is my friend," said the Kurd, with apathy in his voice.
"They hanged him just because he was Kurdish," recalls Massimo Chiodini, the coordinator of the center's temporary shelter program. Two days later, the man tried unsuccessfully to take his life, jumping out of the window of his room on the second floor of the center.
He had fled Iraq. But he could not run away from the unbearable burden of the violence he had witnessed.
Be it a treacherous journey through the Mediterranean on flimsy boats or dodging border patrols, teargas canisters and water cannons in a desperate trek across the Balkans, the migrants' path to Europe is not just a threat to physical integrity. Mental health is at stake too.
At the beginning of September, the German Chamber of Psychotherapists warned authorities that at least half of the refugees arriving in Germany are suffering from trauma-related mental issues, with more than 70 percent of refugees having witnessed violence and around 50 percent having directly experienced it.
Forty per cent of refugee children evaluated in the study had witnessed violence, the chamber's president Dietrich Munz told a press conference. Around a quarter "had to watch family members being attacked," he said.
The United Nations High Committee for Refugees (UNHCR) warned in 2013 that 21.6 percent of Syrians in a refugee camp in Jordan were suffering from anxiety disorders, while 8.5 percent had PTSD.
For Munz, all the symptoms of Post-traumatic Stress Disorder (PTSD) are often present in refugees, who suffer nightmares and flashbacks. He called for more efficient treatment of mentally vulnerable people among refugees; a treatment that cannot solely rely on drugs.
At one clinic in Italy, a country at the forefront of Europe's migrant influx, doctors are doing just that. In Milan, a small psychiatric clinic is providing support to the "psychologically vulnerable individuals" — a bureaucratic umbrella term for traumatized migrants.
"Let me get this straight," Marzia Marzagalia, a kind, soft-spoken psychiatrist specialized in treating victims of torture, told VICE News. "[The migration crisis] is not an emergency anymore. 130,000 people arriving in Italy over ten months is not an emergency. It is a steady migration phenomenon. [The migrants' mental health] is another, far more real, emergency we are trying to deal with here."
The clinic opened in 2003. Then, the majority of the people coming to Italy were economic migrants fleeing African countries and the aftermath of the Balkan war, attracted by the idea of improving their living standards. But migration flows into Europe radically changed over the years. Survival is now the primal urge.
"Since 2011, people have been running for their lives. They flee persecution, rape and torture. They face a deadly journey to Europe as the only alternative," said Marzagalia.
The blossoming and the withering of the Arab Spring, with Libya and Syria descending into mayhem and the so-called Islamic State taking control of large swathes of Iraq, migrants are at far more risk of PTSD.
"They are extremely exposed to a countless number of traumatic experiences," she explained. Trauma related symptoms are not hard to spot, said Marzagalia. "We are talking about physical symptoms such as intense stomach-aches, extreme mental and physical fatigue, and insomnia. In more severe cases we also deal with flashbacks, anxiety crises, dissociative episodes and hallucinations."
The clinic works closely with the reception centers hosting refugees and migrants that have made it to Italy and are aiming to continue their journey towards northern Europe. Social workers at the centers flag concerning behavior to the clinic, if they spot it.
Over the years, Marzagalia has seen many such cases. "This patient from Cameroon had flashbacks. He was basically reliving the moments when he was tortured, over and over again," she said.
PTSD is typically associated with war veterans, who often have intense flashbacks resulting from prolonged exposure to traumatic experiences on the battlefield. Having a flashback means being thrown back to a specific traumatic moment.
"He had a particularly intense flashback with a violent outburst. He tore his room apart," Marzagalia remembers. "He thought he was possessed by a demon, when I saw him for the first time."
Unlike the Kurdish man who tried to take his life, he was taken to the clinic before things could get worse. He started psychotherapy soon after. He managed to control the flashbacks and overcome his trauma.
When talking to Marzagalia about the cases she has seen, it is clear she is withholding most of the details. The intention is protecting her patients, whose recovery is still uncertain. Scars take time to heal.
However, VICE News did learn the story of R., a gay man from Uganda. Last year, he fled the country, where he was being targeted because of his sexuality.
He had been forced to marry a woman and had a child with her. Disowned by his own parents when his wife left him, he was later harassed by the family of the man he'd had a relationship with. He was jailed for the crime of homosexual activities, and was savagely beaten in prison, before managing to escape.
"I can't sleep at night. I wake up anguished," he said, describing the nightmares and anxiety resulting from not just the physical but also the psychological violence he had experienced.
He said despite feeling a huge sense of freedom having made it to Italy, happiness was a long way off. "Nobody cares about my sexual choices [here]," he said. "But I keep telling myself I am selfish. I feel incredibly guilty and sad. I left my whole life behind, even my own son."
Women can be subject to extra, gender-specific forms of trauma. Systematic rape is used in conflicts around the world as a weapon to terrorize civilian populations and destroy social fabrics, with women and girls most often the victims.
In March 2015, a United Nations Security Council report stated that sexual violence had been a characteristic of the Syrian civil war since its inception. According to the UN Population Fund, 38,000 people appealed to the United Nations for help following sexual assault and other gender-based violence in 2013 alone.
The Women Under Siege Project used a crowdsourced map to look at who were the victims and perpetrators of sexual violence during the first two years of the Syrian civil war from 2011 to 2013. Around 80 percent of the cases they documented involved the rape or assault of women and girls, and almost 90 percent of all the attacks were carried out by forces loyal to Bashar Al-Assad's regime. According to WUSP, women and girls were often raped in front of their relatives.
Rape has also been rampant within the IS regime, whose members have captured and traded women and girls from the Yazidi religious minority, claiming rape of unbelievers is allowed and even encouraged by the Qu'ran.
"An appalling number of women that make it to Europe have suffered sexual violence back in their home countries or during their journey. The babies of those who give birth once en route or inside Europe are often conceived after rape," said Marzagalia.
"According the Istanbul protocol (UN guidelines on torture), rape is torture. It leaves the same unspeakable traces in someone's psyche." The activity of the clinic in cases of sexual violence relies on the experience gained from the Bosnian war, during which an estimated 50,000 women were raped. This knowledge is now being used to treat rape survivors from the Middle East and Africa.
"We had an appalling case of this young African woman who was sold and traded as a sex slave throughout all her journey to Europe," Marzagalia, cautious of protecting her patients, told VICE News. "She was so traumatized she lost the ability to speak."
The woman managed to escape her kidnappers. Once she made it to Europe, aid workers flagged her status as "psychologically vulnerable" to the hospital. Many of the women that are being treated in Milan take months, if not years, to tell therapists about their story. According to Marzagalia, all the African woman could hear in her mind were the voices of the men who raped her: her torturers.
"It took months before we could convince her that she was safe here and nobody would have come and taken her away," she said. Even those not affected by PTSD or other mental health conditions when they first arrive may later be affected by post-settlement trauma, once they are attempting to start a new life.
"What if you risked your life to flee your country to reach Europe and you suddenly found out that Europe was just a huge lie, a mirage?" asked Marzagalia. Sometimes the worst part of the journey is realizing Europe is not the place where dreams come true. "How can you cope with the fact that in Syria you were a well-respected journalist for a national daily and, here, you end up washing dishes for a living because you don't have the right to work?" said the doctor. "How can you explain to your family back in Uganda that no, you can't send them money as you are not actually making any?"
This "resettlement crisis" is often made worse by the extremely long procedure to get refugee status. Long waiting lists leave many migrants in a limbo of unemployment and decaying self-esteem that can easily lead to depression and, "if your religion allows it, drug and alcohol abuse," Marzagalia added.
Treating trauma-related vulnerabilities is gradually being recognized as a part of the action plan to cope with the current refugee crisis. Treating trauma is also a way to look at the migrants' long-term future, beyond asylum requests.
Short-sighted solutions can be serious obstacles to psychological treatment of refugees. "We think that we should just give them food and a roof over their heads," said Marzagalia. "But we have to look at the day refugees will go to their homes and start rebuilding, having overcome their traumas"
Aid workers are often not trained to spot PTSD symptoms. That means many traumatized migrants are not treated until something bad happens, said Marzagalia, which could make the problem much worse. "If PTSD symptoms go unnoticed, a person could be [needlessly] hospitalized for life," she said.
Politics also plays a key role. The ethnopsychiatric clinic where Marzagalia works is part of one of the most well-known hospitals in Italy. Not naming the hospital in this piece was a condition for gaining access.
That hospital is overseen by the regional council of Lombardy, currently led by Italian right-wing party Northern League, whose anti-immigration stances have escalated in the last few months.
In a political landscape saturated with roaring slogans such as "Italians first," or "Stop the Invasion," providing support for migrants can make you unpopular.
While Europe is dealing with the most immediate aspects of the crisis — shelter and food — much more has to be done to support the scores of refugees streaming into Europe. In the words of Marzagalia, echoing Dietrich Munz: "It requires stepping up the game. But Europe is probably not yet ready."