Socio-cultural manifestations of PTSD among asylum seekers and refugees: where is the trauma?

2018-6-19, Womersley, Gail

The dual trauma inherent in being both a victim of torture as well a refugee is related to a myriad of losses, human rights violations and other dimensions of suffering. Furthermore, a plethora of research has demonstrated the psychological impact of discrimination and racism experienced by migrants upon arrival to the host country (Akhtar, 1999; Hollander et al., 2016; Kartal & Kiropoulos, 2016). Such research highlights how “racial trauma” (Tummala-Nara, 2007) can have a profound impact on an individual’s sense of self, identity formation, and relationships with others. However, focusing too heavily on trauma risks pathologizing individuals, thereby ignoring wider socio-ecological contexts and denying aspects of resilience. This paper explores resilience as it is experienced by refugees in the context of a relational community (Eades, 2013). Resilience here is considered essentially as a social and environmental attribute (Lusk & Baray, 2017), the capacity of a person’s “informal and formal social networks to facilitate positive development under stress” (Ungar, 2013, p.1). In order to explore trauma and resilience among refugee victims of torture, we present the results of 12 months of research among refugees in a centre for victims of torture in Athens. This research includes 125 in-depth, qualitative interviews with victims of torture, health professionals, cultural mediators/interpreters, and leaders from refugee communities. Case studies illustrate the substantial psychological impact of current material realities of refugee victims of torture as they adapt to their new environment and confront discrimination, and the variety of resources they draw upon to build resilience. Using a socio-ecological framework (Sleijpen, Mooren, Kleber, & Boeije, 2017), we explore the strategies used by this population in order to discuss additional insights of an interpersonal and communal perspective for the growing field of research regarding resilience after traumatic experiences.

2018-10-26, Womersley, Gail

Asylum seekers entering into Europe are often obliged to tell their story to multiple actors (often with a focus on the ‘trauma narrative’) in order to be legally recognized as refugees. Lacking alternative evidence, many attempt to prove their ‘well-founded fear’ and the violence to which they have been exposed through a diagnosis of post-traumatic stress disorder (PTSD). However, the literature highlights the risk of PTSD becoming a ‘pre-requisite’ for validating the experiences of asylum seekers, reifying and reducing these experiences to a diagnosis in order to render accounts believable. To categorize an asylum seeker with PTSD is therefore ‘an act of meaning making,’ entrenched in the habits and discursive practices of medical and legal institutions with very concrete social, material and legal consequences. To explore this, we present the results of a yearlong research projects among asylum seekers diagnosed with PTSD as well as their treating health professionals (including doctors, psychologists and psychiatrists) in a center for victims of torture in Athens, Greece. We analyze the use of the category of PTSD by various actors, notably as factor influencing the decision-making process and the exercise of discretion during the refugee status determination process. The analysis reveals the multiple contradictions in how the various actors involved (including lawyers, bureaucrats, health professionals and the asylum seekers themselves) use this diagnostic construct. We highlight the substantial differences in understanding the diagnosis reflecting existing power imbalances, the way in which narratives of trauma may be purposefully ‘rehearsed’ for the tribunal, and the tensions surrounding the sharing of the trauma narrative within this activity-system.

2017-8-31, Womersley, Gail, Kloetzer, Laure

Europe is living through a refugee crisis of historic proportions which has now become one of the continent’s defining challenges of the early 21st century. Not least among the difficulties are the public health challenges of the multiple traumas faced by this population which constitute severe threats to human, social, cultural, and community development. The psychological impact of atrocities endured by refugees and asylum seekers populations is clear, with the literature reporting significantly high prevalence rates of post-traumatic stress disorder (PTSD) among this population (de Arellano & Danielson, 2008; Kirmayer, Kienzler, Afana, & Pedersen, 2010; Lambert & Alhassoon, 2015; Schweitzer, R., Melville, Steel, & Lacherez, 2006; Steel et al., 2009; Sturm, Baubet, & Moro, 2010; Van Ommeren et al., 2001; Weine, Kuc, Eldin, Razzano, & Pavkovic, 2001). However, there have been significant concerns raised in the literature over the relevance and cross-cultural validity of PTSD as a diagnostic construct (P. Bracken, 2002; P. J. Bracken, 2001; Fisher, 2014; Hinton & Lewis‐Fernández, 2011; Janoff-Bulman, 1985; Kirmayer et al., 2010; Marsella, 2010; Staeuble, 2004; Summerfield, 2001; Tummala-Narra, 2007; Wasco, 2003; Young, 1995). As noted by Roth and Lee (Roth & Lee, 2007), the analytic challenges raised by Vygotsky regarding the “atomistic and functional modes of analysis … [that] treated psychic processes in isolation” (p.1, as cited by Roth and Lee, 2007) remain unresolved. Indeed, one of the principal contributions of the Vygotsky-Luria project is the establishment of a "new psychology" – a ‘decolonized’ way of understanding human thought and activity which takes into consideration the inseparable unity of mind, brain and culture in concrete socio-historical settings (Toomela, 2014). Therefore, consistent with major Vygotskian principles of interactive individual–societal development via the creation of meaning in everyday activities (Daiute & Lucić, 2010), this paper presents the results of a qualitative investigation into experiences of trauma among refugees and asylum seekers. The study incorporates various units of analyses including historicity and context as well as social and material environments in an attempt to go beyond an ‘atomistic’ or individualised framing of psychological difficulties – a particularly relevant consideration for understanding trauma among refugees and asylum seekers in light of the multiple and arguably ongoing environmental stressors with which they are faced as they negotiate material ecologies which both enable and constrain their human activity. It thus offers a subjective analysis of trauma among migrants which takes into account historicity, context, and various levels of analytic scale from within a socio-cultural and historical perspective. Outside of a standardised clinical understanding of trauma, there is a plethora of research indicating that sociocultural and linguistic heritage influences what experiences are interpreted as ‘traumatic,’ the manifestations and expressions of post-traumatic symptomatology, the interpretation of symptoms, narratives of distress as well as culturally-informed healing models (Janoff-Bulman, 1985; Kirmayer et al., 2010; Kleinman & Good, 2004; Luno, Beck, & Louwerse, 2013; Marsella, 2010). As a diagnostic construct developed for use in Western contexts, PTSD has been criticized for ignoring significant variability among symptoms evident in different cultural settings across the world (Hinton & Lewis‐Fernández, 2011; Steel et al., 2009). One example of this variability which continues to attract considerable debate is the prevalence of psychosomatic symptoms found among some cultures and not others (Eagle, 2014). Further criticism is based on the fact that one cannot always link post-traumatic symptoms directly and uncritically to a single event in the life of an individual – a pre-requisite of a PTSD diagnosis by its very definition. Moreover, scholars globally have argued that the location of trauma at the level of the individual in the form of a PTSD diagnosis neglects the broader socio-political and cultural context within which it occurs (Marsella, 2010; Summerfield, 2001; Young, 1995). Such a reductionist discourse potentially individualizes and medicalizes an issue by focusing attention on therapeutic outcomes rather than a political response to the structural issues that led to trauma (Pratt, Johnston, & Banta, 2015). The medicalisation of trauma on an individual level through a psychiatric diagnosis, linked to fixed ‘traumatic’ events in the past, risks rendering us blind to other ongoing aspects of interpersonal, political and social violence on a more global scale, including significant post migration factors which may be deemed equally traumatic by refugees, including current social, political and economic realities and lived daily experiences in host countries (Maier & Straub, 2011; D. Silove, Steel, McGorry, & Mohan, 1998; Derrick Silove, Steel, & Watters, 2000). These criticisms of PTSD therefore highlight the need for a more nuanced, contextualised and ‘decolonized’ understanding of trauma as being significantly determined by larger cultural systems and historic contexts (Carlson, 2005; Dauite, In Press; Kirmayer et al., 2010; Marsella, 2010; Marsella, Friedman, & Spain, 1996; Mattar, 2011; Rousseau, Drapeau, & Corin, 1997; Tummala-Narra, 2007; Wilson, Wilson, & Drozdek, 2004; T. Zittoun, 2014; T. Zittoun, & Sato In press). We will present the results of a 2 month research intervention with NGOs addressing the refugee crisis in Athens, Greece - which included both participant observation and qualitative, in-depth interviews among staff and beneficiaries. Based on principles of ‘action research’ (Reason & Torbert, 2001), the methodology was designed both with regards to the collection of data for research as well as for its potential for transformative action for participants. As such, the design allowed for collaboration with team members of the involved NGOs, local refugee communities and individual beneficiaries, including those diagnosed with PTSD, in order to forge a more direct link between intellectual knowledge and moment-to-moment personal and social action (Reason, 2006; Reason & Torbert, 2001) as well as for an analysis of institutional frameworks. This methodology was similarly inspired by the call of Loizos (Loizos, 2002) for us to invite participants to ‘tell stories’ about themselves at their own speed… [allowing] the suffering persons to represent their ‘illness’ to themselves, perceiving the illness within their own ideas, according to their culture’ (p. 227). Individual participants interviewed were all victims of torture in their respective countries of origin who subsequently sought psychological and medical attention from NGO clinics in Athens, Greece. The 20 refugee community leaders were interviewed in order to broaden our exploration into the multiple traumas to which refugee communities are exposed, and some subjective understandings of ‘PTSD’ as a diagnosis among this population (Schick et al., 2016). By interviewing both individuals as well as community leaders, we attempt to gain a deeper understanding of life trajectories, dynamic processes, interactions and the continual development and change in psychological symptoms; an exploration which equally incorporates a focus on the ever-changing cultural and social systems which determine the various forms of individual subjective experience of psychological difficulties (Ratcliff & Rossi, 2015) The results of these interviews will be presented and open to the audience for discussion. They have been analysed through the lens of activity theory, recently defined by O’Connor as ‘a family of approaches to understanding human mental functioning and action that focuses on how culture, history and social interactions shape individual consciousness’ (p. 1). He examines the various levels in which to make sense of human mental functioning, notably phylogeny (the history of the species), the cultural history of the social group, ontogenesis (the personal history of the individual), and micro-genesis (a microhistory of specific events in the life of the individual, including traumatic events). He draws on Vygotskian theory to illustrate that before a process has landed on a psychological plane, it has to arrive on the social plane. Thus, in examining trauma among refugees, the focus is on ever-changing cultural and social systems which are in continual interaction with the various forms of an individual subjective experience of mental illness. Furthermore, the individuals interviewed are seen as being deeply embedded in complex and dynamic activity systems in which resources are exchanged - wherein individuals are both capable of negotiating and influencing this system as well as being influenced themselves by the system. We will also explore the dynamics of multiple tensions and internal conflicts faced by these individuals in this particular developmental phase of their life trajectories. As such, this presentation aims to draw on a socio-cultural framework which focuses on the intersubjective, mediational space between the individual and culture-society-interaction (O'Connor, 2015); going beyond reductionist labels such as ‘refugee’ or ‘PTSD’ in order to try account for the experience of humans in time and in particular social and cultural environments (T. Zittoun, 2012). Such an approach presupposes human beings inhabit shared forms of life, and utilize semiotic resources (meaning-making and signifying) with reference to social structures and institutions. Meaning is continually negotiated within the social sphere and ‘cultural products, like language and other symbolic systems, mediate thought and place their stamp on our representations of reality’ (Bruner, 1991) (p. 3). This perspective therefore involves a focus on the thread of language and related underlying semiotic systems (T. Zittoun, 2014). It likewise includes a recognition that all languages are composed of different social languages (Bakhtin, 1981; Gee, 2014). Within this framework, we aim to explore, together with the audience, how an individual’s experience of trauma necessarily is influenced by and reflected through language and culture – with culture being considered both as a set of practices physically executed in a tangible and observable sense by the group, as well as integral to belief systems lying internally within individual members (Brewin, Dalgleish, & Joseph, 1996; Drozdek & Wilson, 2007; Sturm, Baubet, & Moro, 2007; Sturm et al., 2010). Such a constructivist approach acknowledges that current concepts of mental health, notably a diagnosis of PTSD, are to some extent socially constructed objects produced within a specific historical period (Ratcliff & Rossi, 2015). The perception of trauma then is mediated through collective memory and the inter-generationally transmitted historic experiences, myths or stories from the past shaping worldviews (Drozdek & Wilson, 2007). Here, elements of temporality will be considered, as well as the continual interaction of the person with their environment in a given social and historical context. The results demonstrate that not only do reactions to trauma differ according to cultural norms, but the very making sense of what is or what is not traumatic may similarly be informed by socio-cultural context (Dauite, In Press; T. Zittoun, 2014; T. Zittoun, & Sato In press). This critical approach goes beyond a reductionist focus on ‘cultural differences’ wherein ‘culture’ is perceived a reified, crystallised concept and viewed as a potential barrier to be overcome in a process of psychiatric classification (Watters, 2001). We thus draw on a Vygotskian view noted by Dauite and Lucic (2010) wherein “ ‘culture’ is not presumed to exist in values or beliefs of ethnicity, gender, or other categories but in the creation of meaning through symbolic thought in situations on the ground. As the primary location of development, social interaction, according to this theory, is not only an influence but the basis for human processes of knowing” (p. 616). The results aim to highlight the heterogeneous, fluid and dynamic nature of individual subjectivities and the multitude of socio-culturally determined discourses which may be drawn upon to make sense of life experiences (Gee, 2014; Squire, 2008), bringing ‘profoundly into question not only the universality of knowledge from one domain to another, but the universal translatability of knowledge from one culture to another (Bruner, 1991)(p. 2). In engaging in such an exploration together with the audience, we aim to contribute to practices of ISCAR by enriching understandings of ‘historical trauma’ (Gone, 2013) or collective, cultural, and identity-related trauma among refugee and asylum seeking populations, with an emphasis on the social location of human subjects and a recognition that trauma responses may carry a sense of group burden and collective suffering beyond symptomatic individuals (Eagle, 2014; T. Zittoun, 2014). Learning about the impact of dislocation, trauma and loss, of political persecution and human malevolence, and social systems involving abuse, neglect, and ethnic and cultural rejection is crucial to understanding the social and historical perspectives of trauma (Wilson et al., 2004).

2017-7-6, Womersley, Gail

2017-9-4, Womersley, Gail

The literature reports significantly high levels of PTSD among asylum seekers, yet the diagnosis is criticized for necessarily requiring one past ‘traumatic’ event – thereby neglecting post-migration factors significantly influencing mental health (Abbott, 2016; Bäärnhielm, 2016; Hall & Olff, 2016; Maercker & Hecker, 2016). To explore the life trajectories of asylum seekers, and more particularly temporal dimensions of experiences of trauma, we present the results of a yearlong qualitative research intervention in Athens. This project includes a longitudinal follow up of 10 asylum seekers, identified as victims of torture and diagnosed with PTSD, as well as 60 interviews with their treating medical professionals and community representatives. We explore the dynamic processes inherent to their life trajectories – focusing on the continual development and change in psychological symptoms of trauma; ever-changing political, cultural and social systems; and how these individuals cope with situations of psychological rupture including experiences of migration (Kadianaki & Zittoun, 2014). Abbott, A. (2016). The troubled minds of migrants. Nature, 538, 158-161. Bäärnhielm, S. (2016). Refugees' mental health-a call for a public health approach with focus on resilience and cultural sensitivity. European Journal of Public Health. doi:10.1093/eurpub/ckw055 Hall, B. J., & Olff, M. (2016). Global mental health: Trauma and adversity among populations in transition. European journal of psychotraumatology, 7. Kadianaki, I., & Zittoun, T. (2014). Catalysts and regulators of psychological change in the context of immigration ruptures The Catalyzing Mind (pp. 191-207): Springer. Maercker, A., & Hecker, T. (2016). Broadening perspectives on trauma and recovery: A socio-interpersonal view of PTSD. European journal of psychotraumatology, 7.

2018-7-3, Womersley, Gail

The mental health impact of atrocities endured by refugees and asylum seekers is clear, with significantly high prevalence rates of post-traumatic stress disorder (PTSD) being reported among this population. Torture has emerged as a particular triggering factor. However, there have been significant concerns raised in the literature over the relevance and cross-cultural validity of this psychiatric diagnosis for refugee populations. Moreover, scholars globally have argued that the location of trauma at the level of the individual in the form of a PTSD diagnosis neglects the broader socio-political and cultural context within which trauma manifests. In order to explore culturally informed representations and perspectives on trauma among refugee victims of torture, we present the results of 12 months of research among asylum seekers and refugees in a center for victims of torture in Athens. This research includes 125 in-depth, qualitative interviews with beneficiaries (refugee victims of torture), health professionals, cultural mediators/interpreters, and leaders from refugee associations and communities across Athens. The results are illustrated using case studies. The majority of refugee victims of torture appear to contest the medicalised notion of « PTSD » with which they had been diagnosed. When referring to their subjective experiences of trauma, they draw upon a variety of diverse cultural representations of suffering (« explanatory models ») and idioms of distress to explain their subjective experiences of trauma. The research findings highlight the need for psychosocial interventions to incorporate a more culturally contextualised understanding of trauma.

2017-9-27, Womersley, Gail

2016-4-15, Womersley, Gail, Kloetzer, Laure

2020-1-7, Womersley, Gail

Greece represents a unique context in which to explore the imagination-(im)mobility nexus: both a transit country and final destination for refugees. This article explores the imagination of refugee victims of torture in Athens as they weave together images of the past, present and future to confer meaning to their current situation and imagine new possible futures. In the context of a growing interest in emotions and temporalities linked to migration, the aim of this paper is thus to explore the complex interplay between the imagination of migrants and the trauma from the theoretical standpoint of sociocultural psychology. The paradoxes are multiple: (i) Migration is inherently imaginative, in the sense that the actualisation of migration begins with individuals imagining their destination; (ii) however, trauma related to forced migration experiences in particular may impede imagination. To further add to the complexity: it may be imagination itself which acts as an essential component to healing from trauma. The article explores forced migrants’ mobility choices and individual migration trajectories to provide insight into how the emotionality of subjective experiences, as well as the sociocultural context, are fundamentally involved in people’s plans to migrate and the development of their ever-changing imagination of a better future elsewhere. The results similarly illustrate imagination as being significantly shaped by the collective imaginings of entire communities.

2016-6-25, Womersley, Gail

Between 1998 and 2006, 65% of medical reports submitted to Swiss authorities in support of asylum claims were based on psychiatric diagnoses, most notably PTSD (Lechenne, 2012). However, PTSD is a diagnosis developed in the West with questionable cross-cultural validity and politically loaded legal implications for asylum seekers. By medicalizing trauma on an individual level based on single events of the past, such diagnoses risk rendering us blind to other ongoing aspects of interpersonal, political and social violence on a more global scale, including significant post migration factors such as the asylum seeking process itself, which may be deemed equally traumatic by migrants (Maier & Straub, 2011; D. Silove, Steel, McGorry, & Mohan, 1998; Derrick Silove, Steel, & Watters, 2000). However, there is also evidence that mental health problems such as PTSD could have a negative impact on asylum seekers’ credibility through affecting the consistency of their verbal accounts of their experiences – thereby creating potential bias against a person genuinely fleeing persecution (Rogers, Fox, & Herlihy, 2015; Turner, 2015). It is therefore argued that a more informed understanding of social and cultural manifestations of trauma and its consequences should play a critical role in informing public health interventions as well as legal policy.